Pascal Bergeron
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A. A governing authority shall:

1. Consist of one or more individuals responsible for the organization, operation, and
administration of an assisted living facility;
2. Establish, in writing, an assisted living facility’s scope of services;
3. Designate, in writing, a manager who:
a. Is 21 years of age or older; and
b. Except for the manager of an adult foster care home, has either a:
i. Certificate as an assisted living facility manager issued under A.R.S. §
36-446.04(C), or
ii. A temporary certificate as an assisted living facility manager issued
under A.R.S. § 36-446.06;
4. Adopt a quality management program that complies with R9-10-804;
5. Review and evaluate the effectiveness of the quality management program at least once
every 12 months;
6. Designate, in writing, an acting manager who has the qualifications established in
subsection (A)(3), if the manager is:
a. Expected not to be present on the assisted living facility’s premises for more than
30 calendar days, or
b. Not present on the assisted living facility’s premises for more than 30 calendar
days;
7. Except as provided in subsection (A)(6), notify the Department according to A.R.S. § 36-
425(I) when there is a change in the manager and identify the name and qualifications of
the new manager;
8. Ensure that a manager or caregiver who is able to read, write, understand, and communicate in English is on an assisted living facility’s premises; and
9. Ensure compliance with A.R.S. § 36-411.

B. A manager:
1. Is directly accountable to the governing authority of an assisted living facility for the
daily operation of the assisted living facility and all services provided by or at the assisted
living facility;
2. Has the authority and responsibility to manage the assisted living facility; and
3. Except as provided in subsection (A)(6), designates, in writing, a caregiver who is:
a. At least 21 years of age, and
b. Present on the assisted living facility’s premises and accountable for the assisted
living facility when the manager is not present on the assisted living facility
premises.

C. A manager shall ensure that policies and procedures are:

1. Established, documented, and implemented to protect the health and safety of a resident
that:
a. Cover job descriptions, duties, and qualifications, including required skills and
knowledge, education, and experience for employees and volunteers;
b. Cover orientation and in-service education for employees and volunteers;
c. Include how an employee may submit a complaint related to resident care;
d. Cover the requirements in A.R.S. Title 36, Chapter 4, Article 11;
e. Except as provided in subsection (M), cover cardiopulmonary resuscitation
training for applicable employees and volunteers, including:
i. The method and content of cardiopulmonary resuscitation training,
which includes a demonstration of the employee’s or volunteer’s ability
to perform cardiopulmonary resuscitation;
ii. The qualifications for an individual to provide cardiopulmonary
resuscitation training;
iii. The time-frame for renewal of cardiopulmonary resuscitation training;
and
iv. The documentation that verifies that the employee or volunteer has
received cardiopulmonary resuscitation training;
f. Cover first aid training;
g. Cover how a caregiver will respond to a resident’s sudden, intense, or out-of control behavior to prevent harm to the resident or another individual;
h. Cover staffing and recordkeeping;
i. Cover resident acceptance and resident rights;
j. Cover termination of residency, including:
i. Termination initiated by the manager of an assisted living facility, and
ii. Termination initiated by a resident or the resident’s representative;
k. Cover the provision of assisted living services, including:
i. Coordinating the provision of assisted living services,
ii. Making vaccination for influenza and pneumonia available to residents
according to A.R.S. § 36-406(1)(d), and
iii. Obtaining resident preferences for food and the provision of assisted
living services;
l. Cover the provision of respite services or adult day health services, if applicable;
m. Cover methods by which the assisted living facility is aware of the general or
specific whereabouts of a resident, based on the level of assisted living services
provided to the resident and the assisted living services the assisted living facility
is authorized to provide;
n. Cover resident medical records, including electronic medical records;
o. Cover personal funds accounts, if applicable;
p. Cover specific steps for:
i. A resident to file a complaint, and
ii. The assisted living facility to respond to a resident’s complaint;
q. Cover health care directives;
r. Cover assistance in the self-administration of medication, and medication
administration;
s. Cover food services;
t. Cover contracted services;
u. Cover equipment inspection and maintenance, if applicable;
v. Cover infection control; and
w. Cover a quality management program, including incident report and supporting
documentation;
2. Available to employees and volunteers of the assisted living facility; and
3. Reviewed at least once every three years and updated as needed.

D. A manager shall ensure that the following are conspicuously posted:

1. A list of resident rights;
2. The assisted living facility’s license;
3. Current phone numbers of:
a. The unit in the Department responsible for licensing and monitoring the assisted
living facility,
b. Adult Protective Services in the Department of Economic Security,
c. The State Long-Term Care Ombudsman, and
d. The Arizona Center for Disability Law; and
4. The location at which a copy of the most recent Department inspection report and any
plan of correction resulting from the Department inspection may be viewed.

E. A manager shall ensure that, unless otherwise stated:

1. Documentation required by this Article is provided to the Department within two hours
after a Department request; and
2. When documentation or information is required by this Chapter to be submitted on behalf
of an assisted living facility, the documentation or information is provided to the unit in
the Department that is responsible for licensing and monitoring the assisted living
facility.

F. If a requirement in this article states that a manager shall ensure an action or condition or sign a
document:

1. A governing authority or licensee may ensure the action or condition or sign the
document and retain the responsibility to ensure compliance with the requirement in this
Article;
2. The manager may delegate ensuring the action or condition or signing the document to
another individual, but the manager retains the responsibility to ensure compliance with
the requirement in the Article; and
3. If the manager delegates ensuring an action or condition or signing a document, the
delegation is documented and the documentation includes the name of the individual to
whom the action, condition, or signing is delegated and the effective date of the
delegation.

G. A manager shall:

1. Not act as a resident’s representative and not allow an employee or a family member of
an employee to act as a resident’s representative for a resident who is not a family
member of the employee;
2. If the assisted living facility administers personal funds accounts for residents and is
authorized in writing by a resident or the resident’s representative to administer a personal funds account for the resident:
a. Ensure that the resident’s personal funds account does not exceed $2,000;
b. Maintain a separate record for each resident’s personal funds account, including
receipts and expenditures;
c. Maintain the resident’s personal funds account separate from any account of the
assisted living facility; and
d. Provide a copy of the record of the resident’s personal funds account to the
resident or the resident’s representative at least once every three months;
3. Notify the resident’s representative, family member, public fiduciary, or trust officer if
the manager determines that a resident is incapable of handling financial affairs; and
4. Except when a resident’s need for assisted living services changes, as documented in the
resident’s service plan, ensure that a resident receives at least 30 calendar days written
notice before any increase in a fee or charge.

H. A manager shall permit the Department to interview an employee, a volunteer, or a resident as
part of a compliance survey or a complaint investigation.

I. If abuse, neglect, or exploitation of a resident is alleged or suspected to have occurred before the
the resident was accepted or while the resident is not on the premises and not receiving services from
an assisted living facility’s manager, caregiver, or assistant caregiver, the manager shall report the
alleged or suspected abuse, neglect, or exploitation of the resident according to A.R.S. § 46-454.

J. If a manager has a reasonable basis, according to A.R.S. § 46-454, to believe abuse, neglect or
exploitation has occurred on the premises or while a resident is receiving services from an
assisted living facility’s manager, caregiver, or assistant caregiver, the manager 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 resident according to A.R.S. §
46-454;
3. Document:
a. The suspected abuse, neglect, or exploitation;
b. Any action is taken according to subsection (J)(1); and
c. The report in subsection (J)(2);
4. Maintain the documentation in subsection (J)(3) for at least 12 months after the date of
the report in subsection(J)(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
(J)(2):
a. The dates, times, and description of the suspected abuse, neglect, or exploitation;
b. A description of any injury to the resident related to the suspected abuse or
neglect and any change to the resident’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 manager 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 (J)(5) for at least
12 months after the date the investigation was initiated.

K. A manager shall provide written notification to the Department of a resident’s:

1. Death, if the resident’s death is required to be reported according to A.R.S. § 11-593, within one working day after the resident’s death; and
2. Self-injury, within two working days after the resident, inflicts self-injury that requires
immediate intervention by an emergency services provider.

L. If a resident is receiving services from a home health agency or hospice service agency, a
manager shall ensure that:

1. The resident’s medical record contains:
a. The name, address, and contact individual, including contact information, of the
home health agency or hospice service agency;
b. Any information provided by the home health agency or hospice service agency;
and
c. A copy of resident follow-up instructions provided to the resident by the home
health agency or hospice service agency; and
2. Any care instructions for a resident provided to the assisted living facility by the home
health agency or hospice service agency are:
a. Within the assisted living facility’s scope of services,
b. Communicated to a caregiver, and
c. Documented in the resident’s service plan.
M. A manager of an assisted living home may establish, in policies and procedures, requirements that
a caregiver obtains and provides documentation of cardiopulmonary resuscitation training
specific to adults, which includes a demonstration of the caregiver’s ability to perform
cardiopulmonary resuscitation, from one of the following organizations:
1. American Red Cross,
2. American Heart Association, or
3. National Safety Council.

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