Arizona Administrative Code
title 9
ARTICLE 2. RIGHTS OF PERSONS WITH SERIOUS MENTAL ILLNESS
R9-21-201. Civil and Other Legal Rights
A. Clients shall have all rights accorded by applicable law, including but not limited to those prescribed in A.R.S. §§ 36-504 through 36-517.02.
Any individual or agency providing behavioral health services or community services as defined in R9-21-101 shall not abridge these rights,
including the following:
1. Those civil rights set forth in A.R.S. § 36-506;
2. The right to acquire and dispose of property, to execute instruments, to enter into contractual relationships, to hold professional
or occupational or vehicle operator’s licenses, unless the client has been adjudicated incompetent or there has been a judicial order or finding
that such client is unable to exercise the specific right or category of rights. In the case of a client adjudicated incompetent, these rights
may be exercised by the client’s guardian, in accordance with applicable law;
3. The right to be free from unlawful discrimination by the Administration or by any mental health agency on the basis of race, creed,
religion, sex, sexual preference, age,
physical or mental handicap or degree of handicap; provided, however, classifications based on age, sex, category or degree of handicap
shall not be considered discriminatory, if based on written criteria of client selection developed by a mental health agency and approved by
the Administration as necessary to the safe operation of the mental health agency and in the best interests of the clients involved;
4. The right to equal access to all existing behavioral health services, community services, and generic services provided by or through the
state of Arizona;
5. The right to religious freedom and practice, without compulsion and according to the preference of the client;
6. The right to vote, unless under guardianship, including reasonable assistance when desired in registering and voting in a nonpartisan
and noncoercive manner;
7. The right to communicate including:
a. The right to have reasonable access to a telephone and reasonable opportunities to make and receive confidential calls and to have
assistance when desired and necessary to implement this right;
b. The unrestricted right to send and receive uncensored and unopened mail, to be provided with stationery and postage in reasonable
amounts, and to receive assistance when desired and necessary to implement this right;
8. The right to be visited and visit with others, provided that reasonable restrictions may be placed on the time and place of the visit
but only to protect the privacy of other clients or to avoid serious disruptions in the normal functioning of the mental health agency;
9. The right to associate with anyone of the client’s choosing, to form associations, and to discuss as a group, with those responsible for
the program, matters of general interest to the client, provided that these do not result in serious disruptions in the normal functioning
of the mental health agency. Clients shall receive cooperation from the mental health agency if they desire to publicize and hold meetings
and clients shall be entitled to invite visitors to attend and participate in such meetings, provided that they do not result in serious
disruptions in the normal functioning of the mental health agency;
10. The right to privacy, including the right not to be fingerprinted and photographed without authorization, except as provided by
A.R.S. § 36-507(2);
11. The right to be informed, in appropriate language and terms, of client rights;
12. The right to assert grievances with respect to infringement of these rights, including the right to have such grievances considered
in a fair, timely, and impartial procedure, as set forth in Article 4 of these rules, and the right not to be retaliated against for filing
a grievance;
13. The right of access to a human rights advocate in order to understand, exercise, and protect a client’s rights;
14. The right to be assisted by an attorney or designated representative of the client’s own choice, including the right to meet in a
private area at the program or facility with an attorney or designated representative. Nothing in this Chapter shall be construed to require
the Administration or any mental health agency to pay for the services of an attorney who consults with or represents a client;
15. The right to exercise all other rights, entitlements, privileges, immunities provided by law, and specifically those rights of consumers
of behavioral health services or community services set forth in A.R.S. §§ 36-504 through 36-517.02;
16. The same civil rights as all other citizens of Arizona, including the right to marry and to obtain a divorce, to have a family, and
to live in the community of their choice without constraints upon their independence, except those constraints to which all citizens are subject.
B. Nothing in this Article shall be interpreted to:
1. Give the power, right, or authority to any person or mental health agency to authorize sterilization, abortion, or psychosurgery with
respect to any client, except as may otherwise be provided by law; or
2. Restrict the right of physicians, nurses, and emergency medical technicians to render emergency care or treatment in accordance with
A.R.S. § 36-512; or
3. Construe this rule to confer constitutional or statutory rights not already present.
R9-21-202. Right to Support and Treatment
A. A client has the following rights with respect to the client’s support and treatment:
1. The right to behavioral health services or community services:
a. Under conditions that support the client’s personal liberty and restrict personal liberty only as provided by law or in this Chapter;
b. From a flexible service system that responds to the client’s needs by increasing, decreasing and changing services as needs change;
c. Provided in a way that:
i. Preserves the client’s human dignity;
ii. Respects the client’s individuality, abilities,
needs, and aspirations without regard to the client’s psychiatric condition;
iii. Encourages the client’s self-determination, freedom of choice, and participation in treatment to the client’s fullest capacity;
iv. Ensures the client’s freedom from the discomfort, distress and deprivation that arise from an
unresponsive and inhumane environment;
v. Protects and promotes the client’s privacy, including an opportunity whenever possible to be provided clearly defined private living,
sleeping and personal care spaces; and
vi. Maximizes integration of the client into the client’s community through housing and residential services which are located in
residential neighborhoods, rely as much as possible on generic support services to provide training and assistance in ordinary community
experiences, and utilize specialized mental health programs that are situated in or near generic community services;
vii. Offers the client humane and adequate support and treatment that is responsive to the client’s needs, recognizes that the
client’s needs may vary, and is capable of adjusting to the client’s changing needs; and
d. That provide the client with an opportunity to:
i. Receive services that are adequate, appropriate, consistent with the client’s individual needs, and least restrictive of the
client’s freedom;
ii. Receive treatment and services that are culturally sensitive in structure, process and content;
iii. Receive services on a voluntary basis to the maximum extent possible and entirely if possible;
iv. Live in the client’s own home;
v. Undergo normal experiences, even though the experiences may entail an element of risk, unless the client’s safety or well-being or
that of others is unreasonably jeopardized; and
vi. Engage in activities and styles of living, consistent with the client’s interests, which encourage and maintain the integration
of the client into the community.
2. The right to ongoing participation in the planning of services as well as participation in the development and periodic revision of the individual
service plan;
3. The right to be provided with a reasonable explanation of all aspects of one’s condition and treatment;
4. The right to give informed consent to all behavioral health services and the right to refuse behavioral health services in accordance with
A.R.S. §§ 36-512 and 36-513, except as provided for in A.R.S. §§ 36-520 through 36-544 and 13-3994;
5. The right not to participate in experimental treatment without voluntary, written informed consent; the right to appropriate protection associated
with such participation; and the right and opportunity to revoke such consent;
6. The right to a humane treatment environment that affords protection from harm, appropriate privacy, and freedom from verbal or physical abuse;
7. The right to enjoy basic goods and services without threat of denial or delay. For residential service providers, these basic goods and services
include at least the following:
a. A nutritionally sound diet of wholesome and tasteful food available at appropriate times and in as normal a manner as possible;
b. Arrangements for or provision of an adequate allowance of neat, clean, appropriate, and seasonable clothing that is individually
chosen and owned;
c. Assistance in securing prompt and adequate medical care, including family planning services, through community medical facilities;
d. Opportunities for social contact in the client’s home, work or schooling environments;
e. Opportunities for daily activities, recreation and physical exercise;
f. The opportunity to keep and use personal possessions; and
g. Access to individual storage space for personal possessions;
8. The right to be informed, in advance, of charges for services;
9. The right to a continuum of care in a unified and cohesive system of community services that is well integrated, facilitates the movement of
clients among programs, and ensures continuity of care;
10. The right to a continuum of care that consists of, but is not limited to, clinical case management, outreach, housing and residential
services, crisis intervention and resolution services, mobile crisis teams, vocational training and opportunities, day treatment, rehabilitation services,
peer support, social support, recreation services, advocacy, family support services, outpatient counseling and treatment, transportation, and
medication evaluation and maintenance;
11. The right to a continuum of care with programs that offer different levels of intensity of services in order to meet the individual needs of each client;
12. The right to appropriate mental health treatment, based on each client’s individual and unique needs, and to those community services from which
the client would reasonably benefit;
13. The right to community services provided in the most normal and least restrictive setting, according to the least restrictive means appropriate to
the client’s needs;
14. The right to clinical case management services and a case manager. The clinical team negotiates and oversees the provision of services and ensures the
` lient’s smooth transition with service providers and among agencies;
15. The right to participate in treatment decisions and in the development and implementation of the client’s ISP, and the right to participate in choosing
the type and location of services, consistent with the ISP;
16. The right to prompt consideration of discharge from an inpatient facility and the identification of the steps necessary to secure a client’s discharge
as part of an ISP;
17. The rights prescribed in Articles 3 and 4 of this Chapter, including the right to:
a. A written individual service plan;
b. Assert grievances; and
c. Be represented by a qualified advocate or other designated representative of the client’s choosing in the development of the ISP and the inpatient
treatment and discharge plan and in the grievance process, in order to understand, exercise and protect the client’s rights.
B. Subsection (A) shall not be construed to confer constitutional or statutory rights not already present.
R9-21-203. Protection from Abuse, Neglect, Exploitation, and Mistreatment
A. No mental health agency shall mistreat a client or permit the mistreatment of a client by staff subject to its direction. Mistreatment includes any intentional,
reckless or negligent action or omission which exposes a client to a serious risk of physical or emotional harm. Mistreatment includes but is not limited to:
1. Abuse, neglect, or exploitation;
2. Corporal punishment;
3. Any other unreasonable use or degree of force or threat of force not necessary to protect the client or another person from bodily harm;
4. Infliction of mental or verbal abuse, such as screaming, ridicule, or name calling;
5. Incitement or encouragement of clients or others to mistreat a client;
6. Transfer or the threat of transfer of a client for punitive reasons;
7. Restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation;
8. Any act in retaliation against a client for reporting any violation of the provisions of this Chapter to the Administration; or
9. Commercial exploitation.
B. The following special sanctions shall be available to the Department and/or the Administration, in addition to those set forth in 9 A.A.C. 10, Article 10 of the
Department’s rules, to protect the interests of the client involved as well as other current and former clients of the mental health agency.
1. Mistreatment of a client by staff or persons subject to the direction of a mental health agency may be grounds for suspension or revocation of the
license of the mental health agency or the provision of financial assistance, and, with respect to employees of the mental health agency, grounds for
disciplinary action, which may include dismissal.
2. Failure of an employee of the Administration to report any instance of mistreatment within any mental health agency subject to this Chapter shall be
grounds for disciplinary action, which may include dismissal.
3. Failure of a mental health agency to report client deaths and allegations of sexual and physical abuse to the Administration and to comply with the
procedures described in Article 4 of this Chapter for the processing and investigation of grievances and reports shall be grounds for suspension of
the license of the mental health agency or the provision of financial assistance, and, with respect to a service provider directly operated by the Department,
grounds for disciplinary action, which may include dismissal.
4. A mental health agency shall report all allegations of mistreatment and denial of rights to the Office of Human Rights and the regional authority for
review and monitoring in accordance with R9-21-105.
C. A mental health agency shall report all incidents of abuse, neglect, or exploitation to the appropriate authorities as required by A.R.S. § 46-454 and shall
document all such reports in the mental health agency’s records.
D. If a mental health agency has reasonable cause to believe that a felony relevant to the functioning of the program has been committed by staff persons subject
to the agency’s direction, a report shall be filed with the county attorney.
E. The identity of persons making reports of abuse, neglect, exploitation, or mistreatment shall not be disclosed by the mental health agency or by the
Administration, except as necessary to investigate the subject matter of the report.
R9-21-204. Restraint and Seclusion
A. A mental health agency shall only use restraint or seclusion to the extent permitted by and in compliance with this Chapter, and other applicable federal or
state law.
B. A mental health agency shall only use restraint or seclusion:
1. To ensure the safety of the client or another individual in an emergency safety situation;
2. After other available less restrictive methods to control the client’s behavior have been tried and were unsuccessful;
3. Until the emergency safety situation ceases and the client’s safety and the safety of others can be ensured, even if the restraint or seclusion order
has not expired; and
4. In a manner that:
a. Prevents physical injury to the client,
b. Minimizes the client’s physical discomfort and mental distress, and
c. Complies with the mental health agency’s policies and procedures required in subsection (E) and with this Section.
C. A mental health agency shall not use restraint or seclusion as a means of coercion, discipline, convenience, or retaliation.
D. A service provider shall at all times have staff qualified on duty to provide:
1. Restraint and seclusion according to this Section, and
2. The behavioral health services the mental health agency is authorized to provide.
E. A mental health agency shall develop and implement written policies and procedures for the use of restraint and seclusion that are consistent
with this Section and other applicable federal or state law and include:
1. Methods of controlling behavior that may prevent the need for restraint or seclusion,
2. Appropriate techniques for placing a client in each type of restraint or seclusion; used at the mental health agency, and
3. Immediate release of a client during an emergency.
F. A mental health agency shall develop and implement a training program on the policies and procedures in subsection (E).
G. A mental health agency shall only use restraint or seclusion according to:
1. A written order given:
a. By a physician providing treatment to a client; or
b. If a physician providing treatment to a client is not present on the premises or on-call:
i. If the agency is licensed as a level 1 psychiatric acute hospital, by a physician or a nurse practitioner; or
ii. If the agency is licensed as a level 1 subacute agency or a level 1 RTC, by a medical practitioner.
2. An oral order given to a nurse by:
a. A physician providing treatment to a client, or
b. If a physician providing treatment to a client is not present on the premises or on-call:
i. If the agency is licensed as a level 1 psychiatric acute hospital, by a physician or a nurse practitioner; or
ii. If the agency is licensed as a level 1 sub-acute agency or a level 1 RTC, by a medical practitioner.
H. If a restraint or seclusion is used according to subsection (G)(2), the individual giving the order shall, at the time of the oral
order in consultation with the nurse, determine whether, based upon the client’s current and past medical, physical and psychiatric
condition, it is clinically necessary for:
1. If the agency is licensed as a level 1 psychiatric acute hospital, a physician to examine the client as soon as possible
and, if applicable, the physician shall examine the client as soon as possible; or
2. If the agency is licensed as a level 1 sub-acute agency or a level 1 RTC, a medical practitioner to examine the client as soon
as possible and, if applicable, the medical practitioner shall examine the client as soon as possible. I. An individual who gives
an order for restraint or seclusion shall:
1. Order the least restrictive restraint or seclusion that may resolve the client’s behavior that is creating the emergency
safety situation, based upon consultation with a staff member at the agency;
2. Be available to the agency for consultation, at least by telephone, throughout the period of the restraint or seclusion;
3. Include the following information on the order:
a. The name of the individual ordering the restraint or seclusion,
b. The date and time that the restraint or seclusion was ordered,
c. The restraint or seclusion ordered,
d. The criteria for release from restraint or seclusion without an additional order, and
e. The maximum duration for the restraint or seclusion;
4. If the order is for mechanical restraint or seclusion, limit the order to a period of time not to exceed three hours.
5. If the order is for a drug used as a restraint, limit the:
a. Dosage to that necessary to achieve the desired effect, and
b. Drug ordered to a drug other than a time-released drug designed to be effective for more than three hours; and
6. If the individual ordering the use of restraint or seclusion is not a physician providing treatment to the client:
a. After ordering the restraint or seclusion, consult with the physician providing treatment as soon as possible, and
b. Inform the physician providing treatment of the client’s behavior that created the emergency safety situation
and required the client to be restrained or placed in seclusion.
J. PRN orders shall not be used for any form of restraint or seclusion.
K. If an individual has not examined the client according to subsection (H), the following individual shall conduct a face-toface assessment
of a client’s physical and psychological wellbeing within one hour after the initiation of restraint or seclusion:
1. For a behavioral health agency licensed as a level 1 psychiatric acute hospital, a physician or nurse practitioner who is
either on-site or on-call at the time the mental health agency initiates the restraint or seclusion; or
2. For a behavioral health agency licensed as a level 1 RTC or a level 1 sub-acute agency a medical practitioner or a
registered nurse with at least one year of full time behavioral health work experience, who is either on-site or oncall at the
time the mental health agency initiates the restraint or seclusion.
L. A face-to-face assessment of a client according to subsection (K) shall include a determination of:
1. The client’s physical and psychological status,
2. The client’s behavior,
3. The appropriateness of the restraint or seclusion used,
4. Whether the emergency safety situation has passed, and
5. Any complication resulting from the restraint or seclusion used.
M. For each restraint or seclusion of a client, a mental health agency shall include in the client’s record the order and any renewal order for
the restraint or seclusion, and shall document in the client’s record:
1. The nature of the restraint or seclusion;
2. The reason for the restraint or seclusion, including the facts and behaviors justifying it;
3. The types of less restrictive alternatives that were attempted and the reasons for the failure of the less restrictive alternatives;
4. The name of each individual authorizing the use of restraint or seclusion and each individual restraining or secluding a client or
monitoring a client who is in restraint or seclusion;
5. The evaluation and assessment of the need for seclusion or restraint conducted by the individual who ordered the restraint or seclusion;
6. The determination and the reasons for the determination made according to subsection (H);
7. The specific and measurable criteria for client release from mechanical restraint or seclusion with documentation to support that the
client was notified of the release criteria and the client’s response;
8. The date and times the restraint or seclusion actually began and ended;
9. The time and results of the face-to-face assessment required in subsection (L);
10. For the monitoring of a client in restraint or seclusion required by subsection (P):
a. The time of the monitoring,
b. The name of the staff member who conducted the monitoring, and
c. The observations made by the staff member during the monitoring; and
11. The outcome of the restraint or seclusion. N. If, at any time during a seclusion or restraint, a medical practitioner or registered nurse
determines that the emergency which justified the seclusion or restraint has subsided, or if the required documentation reflects that the
criteria for release have been met, the client shall be released and the order terminated. The client shall be released no later than the
end of the period of time ordered for the restraint or seclusion, unless a the order for restraint or seclusion is renewed according to
subsection (Q).
O. For any client in restraint, the individual ordering the restraint shall determine whether one-to-one supervision is clinically necessary
and shall document the determination and the reasons for the determination in the client’s record.
P. A mental health agency shall monitor a client in restraint or seclusion as follows:
1. The client shall be personally examined at least every 15 minutes for the purpose of ensuring the client’s general comfort and safety
and determining the client’s need for food, fluid, bathing, and access to the toilet. Personal examinations shall be conducted by staff
members with documented training in the appropriate use of restraint and seclusion and who are working under the supervision of a licensed
physician, nurse practitioner or registered nurse.
2. A registered nurse shall personally examine the client every hour to assess the status of the client’s mental and physical condition and
to ensure the client’s continued well-being.
3. If the client has any medical condition that may be adversely affected by the restraint or seclusion, the client shall be monitored every
five minutes, until the medical condition resolves, if applicable.
4. If other clients have access to a client being restrained or secluded or, if the individual ordering the restraint or seclusion
determines that one-to-one supervision is clinically necessary according to subsection (O), a staff member shall continuously supervise the
client on a one-to one basis.
5. If a mental health agency maintains a client in a mechanical restraint, a staff member shall loosen the mechanical restraints every
15 minutes.
6. Nutritious meals shall not be withheld from a client who is restrained or secluded, if mealtimes fall during the period of restraint.
Staff shall supervise all meals provided to the client while in restraint or seclusion.
7. At least once every two hours, a client who is restrained or secluded shall be given the opportunity to use a toilet.
Q. An order for restraint or seclusion may be renewed as follows:
1. For the first renewal order, the order shall meet the requirements of subsection (G)(1) or (G)(2); and
2. For a renewal order subsequent to the first renewal order:
a. The individual in (G)(1) or (G)(2) shall personally examine the client before giving the renewal order,and
b. The order shall not permit the continuation of the restraint or seclusion for more than 12 consecutive hours unless the
requirements of subsection (P) are met.
R. No restraint or seclusion shall continue for more than 12 consecutive hours without the review and approval by the medical director or
designee of the mental health agency in consultation with the client and relevant staff to discuss and evaluate the needs of the client. The
review and approval, if any, and the reasons justifying any continued restraint or seclusion shall be documented in the client’s record.
S. If a client requires the repeated or continuous use of restraint or seclusion during a 24-hour period, a review process shall be initiated
immediately and shall include the client and all relevant staff persons and clinical consultants who are available to evaluate the need for an
alternative treatment setting and the needs of the client. The review and its findings and recommendations shall be documented in the client’s record.
T. Whenever a client is subjected to extended or repeated orders for restraint or seclusion during a 30-day period, the medical director shall
require a special meeting of the client’s clinical team according to R9-21-314 to determine whether other treatment interventions would be useful
and whether modifications of the ISP or ITDP are required.
U. As part of a mental health agency’s quality assurance program, an audit will be conducted and a report filed with the agency’s medical director
within 24 hours, or the first working day, for every episode of the use of restraint or seclusion to ensure that the agency’s use of seclusion or
restraint is in full compliance with the rules set forth in this Article.
V. Not later than the tenth day of every month, the program director shall prepare and file with the Administration and the Office of Human Rights
a written report describing the use of any form of restraint or seclusion during the preceding month in the mental health agency or by any employees
of the agency. In the case of an inpatient facility, the report shall also be filed with any patient or human rights committee for that facility.
W. The Office of Human Rights, and any applicable human rights committee shall review such reports to determine if there has been any inappropriate
or unlawful use of restraint or seclusion and to determine if restraint or seclusion may be used in a more effective or appropriate fashion.
X. If any human rights committee or the Office of Human Rights determines that restraint or seclusion has been used in violation of any applicable
law or rule, the committee or Office may take whatever action is appropriate, including investigating the matter itself or referring the matter to
the Administration for remedial action.