1. A. An administrator shall ensure that policies and procedures for medication services:

   1. 1. Include:

      1. a. A process for providing information to a patient about medication prescribed for the patient including:

         1. i. The prescribed medication’s anticipated results,
         2. ii. The prescribed medication’s potential adverse reactions,
         3. iii. The prescribed medication’s potential side effects, and
         4. iv. Potential adverse reactions that could result from not taking the medication as prescribed;

      2. b. Procedures for preventing, responding to, and reporting:

         1. i. A medication error,
         2. ii. An adverse reaction to a medication, or
         3. iii. A medication overdose;
      3. c. Procedures to ensure that a patient’s medication regimen is reviewed by a medical practitioner to ensure the medication regimen meets the patient’s needs;
      4. d. Procedures for documenting medication administration and assistance in the self-administration of medication;
      5. e. Procedures for assisting a patient in obtaining medication; and
      6. f. If applicable, procedures for providing medication administration or assistance in the self-administration of medication off the premises; and
      7. g. If applicable, donated medicine according to A.R.S. § 32-1909.

   2. 2. Specify a process for review through the quality management program of:

      1. a. A medication administration error, and
      2. b. An adverse reaction to a medication.

2. B. If a behavioral health inpatient facility provides medication administration, an administrator shall ensure that:

   1. 1. Policies and procedures for medication administration:

      1. a. Are reviewed and approved by a medical practitioner;

      2. b. Specify the individuals who may:

         1. i. Order medication, and
         2. ii. Administer medication;
      3. c. Ensure that medication is administered to a patient only as prescribed; and
      4. d. Cover the documentation of a patient’s refusal to take prescribed medication in the patient’s medical record;
   2. 2. Verbal orders for medication services are taken by a nurse, unless otherwise provided by law; and

   3. 3. A medication administered to a patient is:

      1. a. Administered in compliance with an order, and
      2. b. Documented in the patient’s medical record.

3. C. If a behavioral health inpatient facility provides assistance in the self-administration of medication, an administrator shall ensure that:

   1. 1. A patient’s medication is stored by the behavioral health inpatient facility;

   2. 2. The following assistance is provided to a patient:

      1. a. A reminder when it is time to take the medication;
      2. b. Opening the medication container for the patient;
      3. c. Observing the patient while the patient removes the medication from the container;

      4. d. Verifying that the medication is taken as ordered by the patient’s medical practitioner by confirming that:

         1. i. The patient taking the medication is the individual stated on the medication container label,
         2. ii. The patient is taking the dosage of the medication stated on the medication container label or according to an order from a medical practitioner dated later than the date on the medication container label, and
         3. iii. The patient is taking the medication at the time stated on the medication container label or according to an order from a medical practitioner dated later than the date on the medication container label; or
      5. e. Observing the patient while the patient takes the medication;
   3. 3. Policies and procedures for assistance in the self-administration of medication are reviewed and approved by a medical practitioner or registered nurse;

   4. 4. Training for a personnel member, other than a medical practitioner or registered nurse, in assistance in the self-administration of medication:

      1. a. Is provided by a medical practitioner or registered nurse or an individual trained by a medical practitioner or registered nurse; and

      2. b. Includes:

         1. i. A demonstration of the personnel member’s skills and knowledge necessary to provide assistance in the self-administration of medication,
         2. ii. Identification of medication errors and medical emergencies related to medication that require emergency medical intervention, and
         3. iii. The process for notifying the appropriate entities when an emergency medical intervention is needed;
   5. 5. A personnel member, other than a medical practitioner or registered nurse, completes the training in subsection (C)(4) before the personnel member provides assistance in the self-administration of medication; and

   6. 6. Assistance in the self-administration of medication provided to a patient:

      1. a. Is in compliance with an order, and
      2. b. Is documented in the patient’s medical record.

4. D. An administrator shall ensure that:

   1. 1. A current drug reference guide is available for use by personnel members;
   2. 2. A current toxicology reference guide is available for use by personnel members; and

   3. 3. If pharmaceutical services are provided on the premises:

      1. a. A committee, composed of at least one physician, one pharmacist, and other personnel members as determined by policies and procedures, is established to:

         1. i. Develop a drug formulary,
         2. ii. Update the drug formulary at least once every 12 months,
         3. iii. Develop medication usage and medication substitution policies and procedures, and
         4. iv. Specify which medications and medication classifications are required to be stopped automatically after a specific time period unless the ordering medical practitioner specifically orders otherwise;
      2. b. The pharmaceutical services are provided under the direction of a pharmacist;
      3. c. The pharmaceutical services comply with A.R.S. Title 36, Chapter 27; A.R.S. Title 32, Chapter 18; and 4 A.A.C. 23; and
      4. d. A copy of the pharmacy license is provided to the Department upon request.

5. E. When medication is stored at a behavioral health inpatient facility, an administrator shall ensure that:

   1. 1. Medication is stored in a separate locked room, closet, or self-contained unit used only for medication storage;
   2. 2. Medication is stored according to the instructions on the medication container; and

   3. 3. Policies and procedures are established, documented, and implemented for:

      1. a. Receiving, storing, inventorying, tracking, dispensing, and discarding medication, including expired medication;
      2. b. Discarding or returning prepackaged and sample medication to the manufacturer if the manufacturer requests the discard or return of the medication;
      3. c. A medication recall and notification of patients who received recalled medication; and
      4. d. Storing, inventorying, and dispensing controlled substances.
6. F. An administrator shall ensure that a personnel member immediately reports a medication error or a patient’s adverse reaction to a medication to the medical practitioner who ordered the medication and, if applicable, the behavioral health inpatient facility’s clinical director.

Historical Note

Section R9-10-320, formerly numbered as R9-10-231, renumbered as an emergency effective February 22, 1979, pursuant to A.R.S. § 41-1003, valid for only 90 days (Supp. 79-1). Adopted effective June 14, 1979 (Supp. 79-3). Former Section R9-10-320 repealed, new Section R9-10-320 adopted effective February 4, 1981 (Supp. 81-1). Section repealed by final rulemaking at 8 A.A.R. 2785, effective October 1, 2002 (Supp. 02-2). New Section R9-10-320 made by exempt rulemaking at 19 A.A.R. 2015, effective October 1, 2013 (Supp. 13-2). R9-10-320 renumbered to R9-10-321; new Section R9-10-320 renumbered from R9-10-319 and amended by exempt rulemaking at 20 A.A.R. 1409, pursuant to Laws 2013, Ch. 10, § 13; effective July 1, 2014 (Supp. 14-2). Amended by final rulemaking at 31 A.A.R. 2457 (July 25, 2025), effective August 30, 2025 (Supp. 25-3).