CarePolicy Outpatient Behavioral Health Clinic Policies and Procedures User Guide

CarePolicy Outpatient Behavioral Health Clinic Policies and Procedures User Guide

DOCUMENT CONTROL & APPROVALS

Document revisions shall be recorded in the table below;

Ver. No.| Rev. No.| Page No.| Description of Amendment| Approved By| Date
---|---|---|---|---|---

Document review and approvals shall be recorded in the table below:

Note: All policies and procedures shall be reviewed at least annually, with recommended changes submitted to the governing body for approval, as necessary.

Henceforth, the term “Client(s)” will be referred to as Children, Youth or Parents/Families.

PROGRAM STATEMENT

Purpose and Philosophy

The purpose of this policy is to define organization-wide processes and activities that maximize the
coordination of quality of services to the clients at [AGENCY NAME]. This policy shall be made available
for review, upon request, to clients and their designated representatives and shall be readily available for staff use at all times within [AGENCY NAME].

[AGENCY NAME] shall review this policy at least annually. This policy and procedure manual is developed adhering to all applicable laws and regulations in the state of Arizona.

Our Mission

Dedicated to enhancing the mental health and promoting innovative, culturally and linguistically accessible wellness programs and services of individuals and families in our community and specializing in assisting those in the under-served low-income community.

Our Vision

A sustainable, vibrant, health, engaged, and compassionate Wellness Community.

• Promote health and wellness through healthy lifestyle choices;
• Enhance patient care and patient safety through wellness; and
• Create a safe, healthy work environment for all employees, patients and visitors.

Our Values

[AGENCY NAME] stands by its integrity as a Behavioral Health Outpatient Clinic (BHOC) that can change the community struggling in mental health and substance abuse. As part of the community who is a WRAP around Mental Health will be servicing initial Assessment, Crisis services, therapy, Basic Skills Training (BST), Psychosocial Rehabilitation Services (PSR).

HHHS future goal is to be able to service the full spectrum of Behavioral Health and for any services of inpatient and/or substance abuse treatment and other level of services that are currently not available will be referred to other Behavioral Health Outpatient Clinics that will accept immediate treatment to client. [AGENCY NAME] will coordinate care and work on necessary transfer or discharge to another BHOC.

[AGENCY NAME] Mental Health Outpatient Services program includes medication management services
and it is designed to provide appropriate levels of care to those experiencing significant and acute disruption in their ability to cope with their daily lives.

Coordination of care with their Psychiatrist or Primary Care or referring BHOC is important to establish
common goal in understanding the client’s behavior and approach of an effective treatment plan based
on the client’s history, therapy, environment, medications and triggers for relapse and make an individualized treatment plan according to the medical and clinical history.

[AGENCY NAME] is person centered and focused on empowering the individual to learn about his/her unique needs, strengthen their ability to manage their lives, symptoms, and servic

Services

Crisis Services

Higher Heights crisis intervention services are provided to a person for the purpose of stabilizing or
preventing a sudden, unanticipated, or potentially dangerous behavioral health condition, episode or
behavior. Crisis intervention services are provided in a variety of settings or over the telephone. These
intensive and time limited services may include screening, (e.g., triage and arranging for the provision of
additional crisis services) counseling to stabilize the situation, medication stabilization and monitoring,
observation and/or follow-up to ensure stabilization, and/or other therapeutic and supportive services to
prevent, reduce or eliminate a crisis situation.

Case Management

Supportive and Connective Case Management Teams Case Managers provide a variety of services to meet
members’ needs, individualized to assist them in their recovery.

Some services include home visits, hospital visits, jail visits, helping members to be referred to other
providers in the community for additional treatment or socialization, development of treatment goals,
planning to help in the event of a crisis situation, coordinating with other treatment providers, and
providing ongoing support to members.

Behavioral Health Counseling and Therapy

An interactive therapy designed to elicit or clarify presenting and historical information, identify
behavioral problems or conflicts, and provide support, education or understanding for the person, group
or family to resolve or manage the current problem or conflict and prevent, resolve or manage similar
future problems or conflicts. Services may be provided to an individual, a group of people, a family or
multiple family.

Psychoeducational Services

Services which prepare a person to engage in meaningful work-related activities may include:
career/educational counseling, job shadowing, assistance in the use of educational resources, training in
resume preparation, job interview skills, study skills, work activities, professional decorum and dress, time management, and assistance in finding employment.

Skills Training and Development/ Psychosocial Rehabilitation

Teaching independent living, social, and communication skills to persons and/or their families in order to
maximize the person’s ability to live and participate in the community and to function independently.
Examples of areas that may be addressed include self-care, household management, social decorum,
same- and opposite-sex friendships, and avoidance of exploitation, budgeting, recreation, development
of social support networks and use of community resources. Services may be provided to a person, a
group of individuals or their families with the person(s) present.

Groups

Groups provide a safe environment to talk with others about problems or concerns, learn from others and
better understand yourself. [AGENCY NAME] and Wellness offers a variety of groups at its treatment sites.

Here are just a few:

• Intensive Outpatient Substance Abuse Treatment and Aftercare
• Gender Specific Substance Abuse Education
• Orientation to Treatment
• Gender Specific Empowerment Groups
• Emotional Management
• Anger Management
• DUI
• Domestic Violence
• Living Skills Groups

LGBTQ Affirmative Counseling & Community Support

Cultural attitudes are changing toward the lesbian, gay, bisexual, transgender, or questioning community. Many people look at these gains, and think that the obstacles that keep the LGBTQ community from experiencing the acceptance they deserve have been removed. However, as with any cultural change, progress comes incrementally, and often, we take two steps forward and then one step back. Consider these startling statistics:

• ▪ Members of the LGBTQ community suffer from mental health disorders, such as generalized
  anxiety disorder and major depressive disorder, at a rate that is three times as high as the general population.

• They frequently experience “minority stress” simply for being themselves—treatment like abuse, prejudice, harassment, family rejection, denial of human right, and social exclusion.

• While about 9 percent of the general population experiences substance abuse, about 30 percent of the LGBTQ community experiences substance abuse.

• LGBTQ youth (ages 10-24) experience more prejudice, fear, hatred, and bullying than their peers,
  and suicide is one of their leading causes of death.

It is understandable that members of the LGBTQ may be hesitant to reach out for help when they
experience depression, anxiety, substance abuse, and more. Our desire is to offer sensitive and informed
care to our clients who identify as LGBTQ.

LGBTQ Affirmative Therapy may address topics such as

• How and when to come out
• Dealing with discrimination and non-acceptance
• Depression
• Healthy communication
• Addiction
• Dating and other relationships
• Gender and sexual identity
• Transcending gender roles
• Eating disorders
• Family concerns
• Self-esteem issues
• Anxiety and stress
• Safety concerns
• Past trauma and abuse

Peer Services

Peer Support services provide individual and group support for peers/members. Topics of support may
include support regarding lived experiences such as substance use and behavioral health. Peer services
complement the clinical support offered by psychiatry, counseling, and case management.

Physical Health Services

Higher Heights offers Physical Health services to individuals who have pre- existing health conditions or
just want to maintain a healthy life. Our health professionals will assess, educate and treat your condition.
Our range of services include:

• Health Risk Assessment
• Screenings
• Sleep Assessments
• Allergy
• Medication Management
• Diabetes Management
• Physicals
• Wound Care
• Lab draws
• Vitamin Therapy

Statement of Policy

[AGENCY NAME] prohibit discrimination in all its activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, gender identity, genetic information, and any political beliefs.

[AGENCY NAME] is consistent with the:

• Federal and State Law of Arizona
• Needs of our staff and the community we serve;
• Agency policies and procedures;

We strongly adhere to compliance requirements stated by Arizona State Law, Department of Health and follow the guidelines implemented in terms of policies and procedures within [AGENCY NAME].

STATE POLICIES

Administrative Rules

R9-10-1003. Administration

A. If an outpatient treatment center is operating under a single group license issued to a hospital according to A.R.S. § 36- 422(F) or (G), the hospital’s governing authority is the governing authority for the outpatient treatment center.

B. A governing authority shall:

1. Consist of one or more individuals accountable for the organization, operation, and administration of an outpatient treatment center;

2. Establish, in writing:
   a. An outpatient treatment center’s scope of services, and
   b. Qualifications for an administrator;

3. Designate, in writing, an administrator who has the qualifications established in subsection (B)(2)(b);

4. Adopt a quality management program according to R9-10-1004;

5. Review and evaluate the effectiveness of the quality management program in R9-10-1004 at least once every 12 months;

6. Designate, in writing, an acting administrator who has the qualifications established in subsection (B)(2)(b) if the administrator is:
   a. Expected not to be present on an outpatient treatment center’s premises for more than 30 calendar days, or
   b. Not present on an outpatient treatment center’s premises for more than 30 calendar days; and

7. Except as provided in subsection (B)(6), notify the Department according to A.R.S. § 36-425(I) when there is a change in an administrator and identify the name and qualifications of the new administrator.

C. An administrator:

1. Is directly accountable to the governing authority for the daily operation of the outpatient treatment center and all services provided by or at the outpatient treatment center;
2. Has the authority and responsibility to manage the outpatient treatment center; and
3. Except as provided in subsection (B)(6), designates, in writing, an individual who is present on the outpatient treatment center’s premises and accountable for the outpatient treatment center when the administrator is not available.

D. An administrator shall ensure that:

1. Policies and procedures are established, documented, and implemented to protect the health and safety of a patient that:

   • a. Cover job descriptions, duties, and qualifications, including required skills, knowledge, education, and experience for personnel members, employees, volunteers, and students;
   • b. Cover orientation and in-service education for personnel members, employees, volunteers, and students;
   • c. Include how a personnel member may submit a complaint relating to services provided to a patient;
   • d. Cover the requirements in Title 36, Chapter 4, Article11;
   • e. Cover cardiopulmonary resuscitation training including:

   1. The method and content of cardiopulmonary resuscitation training which includes a demonstration
      of the individual’s ability to perform cardiopulmonary resuscitation,

   2. The qualifications for an individual to provide cardiopulmonary resuscitation training,

   3. The time-frame for renewal of cardiopulmonary resuscitation training, and

   4. The documentation that verifies that an individual has received cardiopulmonary resuscitation training;

   • f. Cover first aid training;

   • g. Include a method to identify a patient to ensure the patient receives the services ordered for the patient;

   • h. Cover patient rights, including assisting a patient who does not speak English or who has a physical or other
     disability to become aware of patient rights;

   • i. Cover health care directives;

   • j. Cover medical records, including electronic medical records;

   • k. Cover quality management, including incident report and supporting documentation; and

   • l. Cover contracted services;

2. Policies and procedures for services provided at or by an outpatient treatment center are established, documented, and implemented to protect the health and safety of a patient that:

   • a. Cover patient screening, admission, assessment, transport, transfer, discharge plan, and discharge;
   • b. Cover the provision of medical services, nursing services, behavioral health services, health related services, and ancillary services;
   • c. Include when general consent and informed consent are required;
   • d. Cover obtaining, administering, storing, and disposing of medications, including provisions for controlling inventory and preventing diversion of controlled substances;
   • e. Cover prescribing a controlled substance to minimize substance abuse by a patient;
   • f. Cover infection control;
   • g. Cover telemedicine, if applicable;
   • h. Cover environmental services that affect patient care;
   • i. Cover specific steps for:
   1. A patient to file a complaint, and
   2.  An outpatient treatment center to respond to a complaint;
   • j. Cover smoking tobacco products on an outpatient treatment center’s premises; and
   • k. Cover how personnel members will respond to a patient’s sudden, intense, or out-of-control behavior to prevent harm to the patient or another individual;

3. Outpatient treatment center policies and procedures are:

   • a. Reviewed at least once every three years and updated as needed, and
   • b. Available to personnel members and employees;

4. Unless otherwise stated:

   • a. Documentation required by this Article is provided to the Department within two hours after a Department request; and
   • b. When do mentation or information is required by this Chapter to be submitted on behalf of an outpatient treatment center, the documentation or information is provided to the unit in the Department that is responsible for licensing and monitoring the outpatient treatment center;

The following are conspicuously posted:

• a. The current license for the outpatient treatment center issued by the Department;
• b. The name, address, and telephone number of the Department;
• c. A notice that a patient may file a complaint with the Department about the outpatient treatment center;
• d. One of the following:
  1. A schedule of rates according to A.R.S. § 36-436.01(C), or
  2. A notice that the schedule of rates required in A.R.S. § 36-436.01(C) is available for review upon request;
• e. A list of patient rights;
• f. A map for evacuating the facility; and
• g. A notice identifying the location on the premises where current license inspection reports required in A.R.S. § 36-425(D), with patient information redacted, are available; an

Patient follow-up instructions are:

• a. Provided, orally or in written form, to a patient or the patient’s representative before the patient leaves the outpatient treatment center unless the patient leaves against a personnel member’s advice; and
• b. Documented in the patient’s medical record.

If abuse, neglect, or exploitation of a patient is alleged or suspected to have occurred before the patient was admitted or while the patient is not on the premises and not receiving services from outpatient treatment center’s employee or personnel member, an administrator shall y report the alleged or suspected abuse, neglect, or exploitation of the patient as follows:

1. For a patient 18 years of age or older, according to A.R.S. § 46-454; or
2. For a patient under 18 years of age, according to A.R.S. § 13-3620.

If an administrator has a reasonable basis, according to A.R.S. § 13-3620 or 46-454, to believe that abuse,
neglect, or exploitation has occurred on the premises or while a patient is receiving services from an outpatient treatment center’s employee or personnel member, an administrator shall:

1. If applicable, take immediate action to stop the suspected abuse, neglect, or exploitation;

2. Report the suspected abuse, neglect, or exploitation of the patient as follows:

   • a. For a patient 18 years of age or older, according to A.R.S. § 46-454; or
   • b. For a patient under 18 years of age, according to A.R.S. § 13-3620

3. Document :

   • a. The suspected abuse, neglect, or exploitation;
   • b. Any action taken according to subsection (F)(1); and
   • c. The report in subsection (F)(2);

4. Maintain the documentation in subsection (F)(3) for at least 12 months after the date of the report in subsection (F)(2);

5. Initiate an investigation of the suspected abuse, neglect, or exploitation and document the following
   information within five working days after the report required in subsection (F)(2):

   • a. The dates, times, and description of the suspected abuse, neglect, or exploitation;

   • b. A description of any injury to the patient related to the suspected abuse or neglect and any change to the
     patient’s physical, cognitive, functional, or emotional condition;

   • c. The names of witnesses to the suspected abuse, neglect, or exploitation; and

   • d. The actions taken by the administrator to prevent the suspected abuse, neglect, or exploitation from occurring in the future; and

6. Maintain a copy of the documented information required in subsection (F)(5) and any other information obtained during the investigation for at least 12 months after the date the investigation was initiated.

   • G. If an outpatient treatment center is an affiliated outpatient treatment center, an administrator shall ensure that the outpatient treatment center complies with the requirements for an affiliated outpatient treatment center in 9 A.A.C. 10, Article 19.

R9-10-1004. Quality Management

An administrator shall ensure that:

1. A plan is established, documented, and implemented for an ongoing quality management program that, at a minimum, includes:
   • a. A method to identify, document, and evaluate incidents;
   • b. A method to collect data to evaluate services provided to patients;
   • c. A method to evaluate the data collected to identify a concern about the delivery of services related to patient care;
   • d. A method to make changes or take action as a result of the identification of a concern about the delivery of services related to patient care; and
   • e. The frequency of submitting a documented report required in subsection (2) to the governing authority;
2. A documented report is submitted to the governing authority that includes:
   • a. An identification of each concern about the delivery of services related to patient care, and
   • b. Any change made or action taken as a result of the identification of a concern about the delivery of services related to patient care; and
3. The report required in subsection (2) and the supporting documentation for the report are maintained for at least 12 months after the date the report is submitted to the governing authority.

R9-10-1006. Personnel

An administrator shall ensure that:

1. Policies and procedures are established, documented, and implemented to protect the health and safety of a patient that:

   • a. Cover job descriptions, duties, and qualifications, including required skills, knowledge, education, and experience for personnel members, employees, volunteers, and students;
   • b. Cover orientation and in-service education for personnel members, employees, volunteers, and students;
   • c. Include how a personnel member may submit a complaint relating to services provided to a patient;
   • d. Cover the requirements in Title 36, Chapter 4, Article11;
   • e. Cover cardiopulmonary resuscitation training
     including:
   1. The method and content of cardiopulmonary resuscitation training which includes a demonstration of the individual’s ability to perform cardiopulmonary resuscitation,
   2. The qualifications for an individual to provide cardiopulmonary resuscitation training,
   3. The time-frame for renewal of cardiopulmonary resuscitation training, and
   4. iv. The documentation that verifies that an individual has received cardiopulmonary resuscitation training;
   • f. Cover first aid training;
   • g. Include a method to identify a patient to ensure the patient receives the services ordered for the patient;
   • h. Cover patient rights, including assisting a patient who does not speak English or who has a physical or other disability to become aware of patient rights;
   • i. Cover health care directives;
   • j. Cover medical records, including electronic medical records;
   • k. Cover quality management, including incident report and supporting documentation; and
   • l. Cover contracted services;

2. Policies and procedures for services provided at or by an outpatient treatment center are established,
   documented, and implemented to protect the health and safety of a patient that:

   • a. Cover patient screening, admission, assessment, transport, transfer, discharge plan, and discharge; b. Cover the provision of medical services, nursing services, behavioral health services,
   • health-related services, and ancillary services;
   • c. Include when general consent and informed consent are required;
   • d. Cover obtaining, administering, storing, and disposing of medications, including provisions for controlling inventory and preventing diversion of controlled substances;
   • e. Cover prescribing a controlled substance to minimize substance abuse by a patient;
   • f. Cover infection control;
   • g. Cover telemedicine, if applicable;
   • h. Cover environmental services that affect patient care;
   • i. Cover specific steps for:
   1. A patient to file a complaint, and
   2. An outpatient treatment center to respond to a complaint;
   • j. Cover smoking tobacco products on an outpatient treatment center’s premises; and
   • k. Cover how personnel members will respond to a patient’s sudden, intense, or out-of-control behavior to prevent harm to the patient or another individual;

3. Outpatient treatment center policies and procedures are:

   • a. Reviewed at least once every three years and updated as needed, and
   • b. Available to personnel members and employees;

4. Unless otherwise stated:

   • a. Documentation required by this Article is provided to the Department within two hours after a Department request; and
   • b. When documentation or information is required by this Chapter to be submitted on behalf of an outpatient treatment center, the documentation or information is provided to the unit in the Department that is responsible for licensing and monitoring the outpatient treatment center;

5. The following are conspicuously posted:

   • a. The current license for the outpatient treatment center issued by the Department;
   • b. The name, address, and telephone number of the Department;
   • c. A notice that a patient may file a complaint with the Department about the outpatient treatment center;
   • d. One of the following:
   1. A schedule of rates according to A.R.S. § 36-436.01(C), or
   2. A notice that the schedule of rates required in A.R.S. § 36-436.01(C) is available for review upon request;
   • e. A list of patient rights;
   • f. A map for evacuating the facility; and
   • g. A notice identifying the location on the premises where current license inspection reports required in A.R.S.
   • 36-425(D), with patient information redacted, are available; and

6. Patient follow-up instructions are:

   • a. Provided, orally or in written form, to a patient or the patient’s representative before the patient leaves the outpatient treatment center unless the patient leaves against a personnel member’s advice; and
   • b. Documented in the patient’s medical record.

If abuse, neglect, or exploitation of a patient is alleged or suspected to have occurred before the patient was admitted or while the patient is not on the premises and not receiving services from outpatient treatment center’s employee or personnel member, an administrator shall y report the alleged or suspected abuse, neglect, or exploitation of the patient as follows:

1. For a patient 18 years of age or older, according to A.R.S. § 46-454; or
2. For a patient under 18 years of age, according to A.R.S. § 13-3620.

If an administrator has a reasonable basis, according to A.R.S. § 13-3620 or 46-454, to believe that abuse, neglect, or exploitation has occurred on the premises or while a patient is receiving services from an outpatient treatment center’s employee or personnel member, an administrator shall:

1. If applicable, take immediate action to stop the suspected abuse, neglect, or exploitation;

2. Report the suspected abuse, neglect, or exploitation of the patient as follows:

   • a. For a patient 18 years of age or older, according to A.R.S. § 46-454; or
   • b. For a patient under 18 years of age, according to A.R.S. § 13-3620;

3. Document:
   a. The suspected abuse, neglect, or exploitation;
   b. Any action taken according to subsection (F)(1); and
   c. The report in subsection (F)(2);

4. Maintain the documentation in subsection (F)(3) for at least 12 months after the date of the report in subsection (F)(2);

5. Initiate an investigation of the suspected abuse, neglect, or exploitation and document the following information within five working days after the report required in subsection (F)(2):

   • a. The dates, times, and description of the suspected abuse, neglect, or exploitation;
   • b. A description of any injury to the patient related to the suspected abuse or neglect and any change to the patient’s physical, cognitive, functional, or emotional condition;
   • c. The names of witnesses to the suspected abuse, neglect, or exploitation; and
   • d. The actions taken by the administrator to prevent the suspected abuse, neglect, or exploitation from occurringin the future; and

6. Maintain a copy of the documented information required in subsection (F)(5) and any other information obtained during the investigation for at least 12 months after the date the investigation was initiated.

   • If an outpatient treatment center is an affiliated outpatient treatment center, an administrator shall ensure that the outpatient treatment center complies with the requirements for an affiliated outpatient treatment center in 9 A.A.C. 10, Article 19.

An administrator shall ensure that:

1. A plan is established, documented, and implemented for an ongoing quality management program that, at a minimum, includes:
   • a. A method to identify, document, and evaluate incidents;
   • b. A method to collect data to evaluate services provided to patients;
   • c. A method to evaluate the data collected to identify a concern about the delivery of services related to patient care;
   • d. A method to make changes or take action as a result of the identification of a concern about the delivery of services related to patient care; and
   • e. The frequency of submitting a documented report required in subsection (2) to the governing authority;
2. A documented report is submitted to the governing authority that includes:
   • a. An identification of each concern about the delivery of services related to patient care, and
   • b. Any change made or action taken as a result of the identification of a concern about the delivery of services related to patient care; and
3. The report required in subsection (2) and the supporting documentation for the report are maintained for at least 12 months after the date the report is submitted to the governing authority.

An administrator shall ensure that:

1. The qualifications, skills, and knowledge required for each type of personnel member:

   • a. Are based on:
   1. The type of physical health services or behavioral health services expected to be provided by
      the personnel member according to the established job description, and
      ii. The acuity of the patients receiving physical health services or behavioral health services from the personnel member according to the established job description; and
   • b. Include:
   1. The specific skills and knowledge necessary for the personnel member to provide the expected physical health services and behavioral health services listed in the established job description,
   2. The type and duration of education that may allow the personnel member to have acquired the specific skills and knowledge for the personnel member to provide the expected physical health services or behavioral health services listed in the established job description, and
   3. The type and duration of experience that may allow the personnel member to have acquired the specific skills and knowledge for the personnel member to provide the expected physical health services or behavioral health services listed in the established job description;

2. A personnel member’s skills and knowledge are verified and documented:

   • a. Before the personnel member provides physical health services or behavioral health services, and
   • b. According to policies and procedures;

3. Sufficient personnel members are present on an outpatient treatment center’s premises with the qualifications, skills, and knowledge necessary to:

   • a. Provide the services in the outpatient treatment center’s scope of services,
   • b. Meet the needs of a patient, and
   • c. Ensure the health and safety of a patient;

4. A personnel member only provides physical health services or behavioral health services the personnel member is qualified to provide;

5. A plan is developed, documented, and implemented toprovide orientation specific to the duties of personnel members, employees, volunteers, and students;

6. A personnel member completes orientation before providing medical services, nursing services or health related services to a patient;

7. An individual’s orientation is documented, to include:

   • a. The individual’s name,
   • b. The date of the orientation, and
   • c. The subject or topics covered in the orientation;

8. A plan is developed, documented, and implemented to provide in-service education specific to the duties ofa personnel member;

9. A personnel member’s in-service education is documented, to include:

   • a. The personnel member’s name,
   • b. The date of the in-service education, and
   • c. The subject or topics covered in the in-service education;

10. A personnel member who is a behavioral health technician or behavioral health paraprofessional complies
    with the applicable requirements in R9-10-115;

11. A record for a personnel member, an employee, a volunteer, or a student is maintained that includes:

    • a. The individual’s name, date of birth, and contact telephone number;
    • b. The individual’s starting date of employment or volunteer service, and if applicable, the ending date;
    • c. Documentation of:
    1. The individual’s qualifications including skills and knowledge applicable to the individual’s job duties;
    2. The individual’s education and experience applicable to the individual’s job duties;
    3. The individual’s completed orientation and in service education as required by policies and procedures;
    4. The individual’s license or certification, if the individual is required to be licensed or certified in this Article or policies and procedures;
    5. If the individual is a behavioral health technician, clinical oversight required in R9 10-115;
    6.  The individual’s compliance with the fingerprinting requirements in A.R.S. § 36-425.03, if applicable; and
    7. Cardiopulmonary resuscitation training, if the individual is required to have cardiopulmonary resuscitation training according to this Article or policies and procedures; and

12. The record in subsection (A)(11) is:

    • a. Maintained while an individual provides services for or at the outpatient treatment center and for at least 24 months after the last date the employee or volunteer provided services for or at the outpatient treatment center; and
    • b. If the ending date of employment or volunteer service was 12 or more months before the date of the Department’s request, provided to the Department within 72 hours after the Department’s request.

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