Arizona ADHS Inspections -

All reports have been sourced from publicly available documents at https://www.azdhs.gov/licensing/index.php#azcarecheck. Inspections that revealed violations are highlighted in orange.

A CARING COMMUNITY LLC
3931 West Sweetwater Avenue, Phoenix, AZ 85029

Compliance (Annual) on 6/2/2025

Rule: R9-10-113.A.1-2. Tuberculosis Screening A. If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution’s chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that:

1. Are consistent with recommendations in Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019, published by the U.S. Department of Health and Human Services, Atlanta, GA 30333, available at https://www.cdc.gov/mmwr/volumes/68/wr/m m6819a3.htm, incorporated by reference, on file with the Department, and including no future editions or amendments; and

2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual’s freedom from infectious tuberculosis according to subsection (B)(1); b. If an individual may have a latent tuberculosis infection, as defined in A.A.C. R9-6-1201: i. Referring the individual for assessment or treatment; and
Evidence: Based on documentation review, record review, and interview, the health care institution failed to establish and document tuberculosis (TB) infection control activities as specified in R9-10-113(A)(1)(2). The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees, and posed a potential TB exposure risk to residents.

Findings:

1. A review of facility documentation revealed no infection control activities to cover TB infection control to protect the health and safety of a resident.

2. A review of facility documentation revealed a policy and procedure titled “Section 17: Infection Control” (dated September 1, 2024). However, the policy and procedure did not cover TB infection control to protect the health and safety of a resident.

3. A review of R1’s (admitted in 2025) medical record revealed no documentation of baseline screening, consisting of assessing risks of prior exposure to infectious TB and determining if the individual had signs or symptoms of TB.

4. In an exit interview, the findings were reviewed with E1, and no additional comments, statements, or documentation were provided regarding the findings. ii. Annually obtaining documentation of the individual’s freedom from symptoms of infectious tuberculosis, signed by a medical practitioner, occupation health provider, as defined in A.A.C. R9-6-801, or local health agency, as defined in A.A.C. R9-6-101; c. Annually providing training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed by or providing volunteer services for the health care institution; d. Annually assessing the health care institution’s risk of exposure to infectious tuberculosis; e. Reporting, as specified in A.A.C. R9-6-202, an individual who is suspected of exposure to infectious tuberculosis; and f. If an exposure to infectious tuberculosis occurs in the health care institution, coordinating and sharing information with the local health agency, as defined in A.A.C. R9-6-101, for identifying, locating, and investigating contacts, as defined in A.A.C. R9-6-101. Technical assistance was provided on this Rule during the on-site compliance inspection conducted on May 20, 2024. Technical assistance was provided on this Rule during the on-site compliance inspection conducted on February 24, 2023.

Rule: R9-10-707.A.10.b. Admission; Assessment A. An administrator shall ensure that: 10. If a behavioral health assessment that complies with the requirements in this Section is received from a behavioral health provider other than the behavioral health residential facility or if the behavioral health residential facility has a medical record for the resident that contains a behavioral health assessment that was completed within 12 months before the date of the resident’s current admission: b. The review and update of the resident’s assessment information is documented in the resident’s medical record within 48 hours after the review is completed;
Evidence: Based on record review and interview, the administrator failed to ensure a behavioral health assessment in compliance with the requirements in R9-10-707(A)(11), received from a behavioral health provider other than the behavioral health residential facility, was reviewed, updated, and documented in the resident’s medical record within 48 hours after the review was completed, for one of two residents sampled. The deficient practice posed a risk to the health and safety of the resident if the behavioral health assessment was not reviewed and approved to meet the resident’s needs, and the repeated violation shows a pattern of noncompliance to ensure the health and safety of residents.

Findings:

1. A review of R1’s (admitted in 2025) medical record revealed behavioral health assessments (dated August 2024 and September 2024) from a behavioral health provider other than BH6807. However, no documentation of a review and update of R1’s assessment information was available for review.

2. In an interview, E1 reported R1’s behavioral health assessments were reviewed by E2; however, this information was not documented.

3. In an exit interview, the findings were reviewed with E1, and no additional comments, statements, or documentation were provided regarding the findings. This is a repeat violation from the on-site compliance inspection conducted on February 24, 2023.

Rule: R9-10-707.A.13.b. Admission; Assessment A. An administrator shall ensure that: 13. Except as provided in subsection (E)(1)(d), a resident provides
Evidence: of freedom from infectious tuberculosis: b. As specified in R9-10-113. Evidence Based on record review and interview, the administrator failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of two residents sampled. The deficient practice posed a potential TB exposure risk to residents.

Findings: R9-10-113(A)(2) If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution’s chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that:

1. A review of R1’s (admitted in 2025) medical record revealed documentation of a Mantoux TB skin test. However, no documentation of baseline screening consisting of assessing risks of prior exposure to infectious TB and determining if the individual had signs or symptoms of TB was available for review.

2. In an interview, E1 reported R1’s baseline screening consisting of assessing risks of prior exposure to infectious TB and determining if the individual had signs or symptoms of TB was not completed.

3. In an exit interview, the findings were reviewed with E1, and no additional comments, statements, or documentation were provided regarding the findings. Technical assistance was provided on this Rule during the on-site compliance inspection conducted on May 20, 2024. Technical assistance was provided on this Rule during the on-site compliance inspection conducted on February 24, 2023.

Rule: R9-10-708.A.6.a. Treatment Plan A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that:

6. Is reviewed and updated on an on-going basis: a. According to the review date specified in the treatment plan,
Evidence: Based on record review and interview, the administrator failed to ensure a treatment plan was reviewed and updated on an on-going basis according to the review date specified in the treatment plan, for one of two current residents sampled. The deficient practice posed a risk as an updated treatment plan was not completed to articulate decisions and agreements of services to be provided.

Findings:

1. A review of R1’s (admitted in 2025) medical record revealed a treatment plan (dated in 2025). The treatment plan stated ” . Next Review Date: 04/26/2025.” However, no documentation of a treatment plan updated according to the review date specified in the treatment plan was available for review.

2. In an interview, E1 stated R1’s treatment plan was “probably” not updated according to the review date specified in the treatment plan. E1 reported not to have a current treatment plan available for R1.

3. In an exit interview, the findings were reviewed with E1, and no additional comments, statements, or documentation were provided regarding the findings.

Complaint on 6/15/2023 – 6/22/2023

Rule: G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes:

Findings: A.R.S. \’a7 36- 425.03(E) states “Children’s behavioral health program personnel shall certify on forms that are provided by the department and notarized that they are not awaiting trial on or have never been convicted of or admitted in open court or pursuant to a plea agreement to committing any of the offenses listed in section 41-1758.03, subsection B or C in this state or similar offenses in another state or jurisdiction.”

1. A review of E6’s (hired in 2023) personnel record revealed E6 was hired as a behavioral health technician (BHT). E6’s personnel record revealed a valid fingerprint clearance card and a form (dated January 16, 2023) indicating E6 was not awaiting trial on or have never been convicted of or admitted in open court or pursuant to a plea agreement to committing any of the offenses listed in section 41-1758.03, subsection B or C in this state or similar offenses in another state or jurisdiction. However, the form was not notarized.

2. In an interview, E2 reported E2 believed E6 had a notarized form indicating E6 was not awaiting trial on or have never been convicted of or admitted in open court or pursuant to a plea agreement to committing any of the offenses listed in section 41-1758.03, subsection B or C in this state or similar offenses in another state or jurisdiction

3. In an interview, E2 acknowledged E6’s personnel record was not maintained to include documentation of compliance with the requirements in A.R.S. \’a7\’a7 36-425.03(E). This is a repeat deficiency from the compliance inspection conducted on February 24, 2023. Date permanent correction will be complete: 2023-06-30

Rule: A. An administrator shall ensure that: 7. A resident does not: a. Use or have access to any materials, furnishings, or equipment or participate in any activity or treatment that may present a threat to the resident’s health or safety based on the resident’s documented diagnosis, treatment needs, developmental levels, social skills, verbal skills, or personal history; or
Evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a resident did not participate in any activity to present a threat to the resident’s health or safety based on the resident’s documented diagnosis, treatment needs, developmental levels, social skills, verbal skills, or personal history. The deficient practice posed a risk as residents participated in an activity where a registered sex offender was present.

Findings:

1. A review of Department documentation revealed BH6807 was licensed as a children’s behavioral health residential facility with a capacity of five beds.

2. A review of medical records revealed AL6809 had five residents.

3. A review of the Arizona E-Licensing database for Arizona Professional Licensure (https://elicense.az.gov/ARDC_HomePage) revealed O1 was licensed as a student barber with the Arizona State Board of Barbers. The database revealed an address to correlate with cross streets provided by E2 for O1’s place of business.

4. In an interview, R1 reported R1 received haircut services from O1.

5. In an interview, E1 reported the residents received haircut services from O1. E1 reported the residents and O1 were always supervised.

6. In an interview, E2 reported the residents received haircut services from O1. E2 reported E2 did not know the name of the barbershop but provided the Compliance Officers with the cross streets. 7. A review of facility documentation revealed a receipt for haircut services (dated June 7, 2023). The receipt stated “Hey [E1], Thanks for booking with [O1] using theCut! APPOINTMENT Hair Cuts For Kids Under 18.” 8. In an interview, R1 reported R1 observed O1 on the premises to fix a broken toilet. 9. In an interview, E2 stated the toilet O1 fixed the toilet “this week” and the toilet “flooded on Tuesday.” 10. In an interview, E1 reported O1 only does minor work at the facility. E1 reported O1 was at the facility to fix the toilet and to install outdoor screens on the windows. E1 reported the residents and O1 were always supervised. 11. In an interview, E1 reported E1 was aware of O1’s background. E1 reported E1 takes O1’s background seriously and O1 was not involved in the behavioral health residential facility. 12. In an interview, E2 reported E2 was aware O1 does minor work at the facility. E2 reported E2 has never personally seen O1 on the premises. E2 reported E2 believed the residents and O1 were always supervised. 13. In an interview, E2 acknowledged E1 failed to ensure a resident did not participate in any activity to present a threat to the resident’s health or safety. 14. A review of the State of Idaho court cases website (https://mycourts.idaho.gov/) revealed a Criminal Court Case Information Case History for O1. The website stated “Rape- Female Under the age of 18 (Statutory Rape)” in 2001; “PROBATION VIOLATION” in 2006; “Probation Violation” in 2008; and “Sex Offender-Give False Information in Registration . Sex Offender-Fail to Register or Give False Information” in 2009. 15. In an email, received by the Department on June 22, 2023, a representative from the Arizona Department of Public Safety (AZDPS), O2, reported O1 was currently registered as a sex offender in Arizona. Plan of Correction Name, title and/or Position of the Person Responsible Date temporary correction was implemented Date permanent correction will be complete 2023-07-15

Compliance (Annual) on 5/20/2024

Rule: G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes:

3. Documentation of: e. The individual’s compliance with requirements in A.R.S. §§ 36-411, 36-411.01, and 36-425.03, as applicable;
Evidence: Based on observation, record review, documentation review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of compliance with the requirements in A.R.S. \’a7\’a7 36-425.03(A), for one of seven personnel records sampled. The deficient practice posed a risk if E5 was a danger to a vulnerable population.

Findings: A.R.S. \’a7 36-425.03(A) states “Except as provided in subsections B, C and D of this section, children’s behavioral health program personnel, including volunteers, shall submit the form prescribed in subsection E of this section to the employer and shall have a valid fingerprint clearance card issued pursuant to title 41, chapter 12, article

3.1 or, within seven working days after employment or beginning volunteer work, shall apply for a fingerprint clearance card.”

1. The Compliance Officer observed E5 on the premises and working alone when the Compliance Officer arrived at 8:45AM.

2. A review of E5’s (hired in 2021) personnel record revealed E5 was hired as a behavioral health technician. E5’s personnel record revealed a fingerprint clearance card (issued February 22, 2018, expired February 22, 2024). However, documentation of a valid fingerprint clearance card was not available for review.

3. A review of the Arizona Department of Public Safety (AZDPS) Fingerprint Clearance Status website revealed E5’s fingerprint clearance card application was received by AZDPS on February 13, 2024 and the status was “Waiting on Applicant Fingerprints.”

4. In an interview, E1 acknowledged E5’s personnel record was not maintained to include documentation of compliance with the requirements in A.R.S. \’a7\’a7 36-425.03(A). Date permanent correction will be complete: 2024-06-01

Rule: K. An administrator shall ensure that:

3. There is a daily staffing schedule that: a. Indicates the date, scheduled work hours, and name of each employee assigned to work, including on-call personnel members;
Evidence: Based on documentation review and interview, the administrator failed to ensure there was a daily staffing schedule to indicate the scheduled work hours, and name of each employee assigned to work, including on-call personnel members. The deficient practice posed a risk if there was no record to ensure shifts and tasks were covered. Findings include:

1. A review of facility documentation revealed a daily staffing schedule for April 28, 2024-May 26, 2024. However, the daily staffing schedule did not include the behavioral health professional and registered nurse as on- call personnel members.

2. In an interview, E1 acknowledged the daily staffing schedules indicating the date, scheduled work hours, and name of each employee assigned to work, did not include the behavioral health professional and registered nurse as on-call personnel members. Date permanent correction will be complete: 2024-06-01

Findings:

Rule: A. An administrator shall ensure that:

6. Except as provided in subsection (E)(1)(a), a medical practitioner performs a medical history and physical examination or a registered nurse performs a nursing assessment on a resident within 30 calendar days before admission or within 72 hours after admission and documents the medical history and physical examination or nursing assessment in the resident’s medical record within 72 hours after admission;
Evidence: Based on record review and interview, the administrator failed to ensure a medical practitioner performed a medical history and physical examination or a registered nurse performed a nursing assessment on a resident within 30 calendar days before admission or within 72 hours after admission and documented the medical history and physical examination or nursing assessment in the resident’s medical record within 72 hours after admission, for one of two residents sampled. The deficient practice posed a risk as this information was required for the development and implementation of a treatment plan, per R9-10-708.A.1.

Findings:

1. A review of R2’s (admitted in 2024) medical record revealed a medical history and physical examination performed by a medical practitioner or a nursing assessment performed by a registered nurse was not available for review.

2. In an interview, E1 reported a medical history and physical examination performed by a medical practitioner or a nursing assessment performed by a registered nurse had not been performed.

3. In an interview, E1 acknowledged a medical history and physical examination performed by a medical practitioner or a nursing assessment performed by a registered nurse was not available for review. Date permanent correction will be complete: 2024-06-01

Findings:

1. A review of R1’s (admitted in 2023) medical record revealed evidence of freedom from infectious TB, before or within seven calendar days after R1’s admission, and as specified in R9-10-113, was not available for review.

2. In an interview, E1 reported R1 did not have documentation of evidence of freedom from infectious TB and acknowledged R1’s evidence of freedom from infectious TB was not available for review. Date permanent correction will be complete: 2024-06-01

Rule: A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that:

4. Includes: b. The physical health services or behavioral health services to be provided to the resident;
Evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a treatment plan included the behavioral health services to be provided to the resident, for two of two residents sampled. The deficient practice posed a risk as a treatment plan was not developed to articulate decisions and agreements of services to be provided.

Findings: R9-10-101.24. “Assistance in the self-administration of medication” means restricting a patient’s access to the patient’s medication and providing support to the patient while the patient takes the medication to ensure that the medication is taken as ordered. R9-10- 101.135. “Medication administration” means restricting a patient’s access to the patient’s medication and providing the medication to the patient or applying the medication to the patient’s body, as ordered by a medical practitioner.

1. A review of facility documentation revealed a scope of services (date unavailable). The scope of services stated “. SERVICES Provided daily: Assistance in the self-administration of medication.”

2. A review of R1’s (admitted in 2023) medical record revealed a treatment plan (dated in 2023). However, R1’s treatment plan did not include whether medication administration or assistance in the self-administration of medication was to be provided to R1 .

3. A review of R2’s (admitted in 2024) medical record revealed a treatment plan (dated in 2024). However, R2’s treatment plan did not include whether medication administration or assistance in the self-administration of medication was to be provided to R2 .

4. In an interview, E1 reported medication administration was provided to R1, R2, and all residents by prepping the medications and placing the medications in a cup, and handing the cup to the residents.

5. In an interview, E1 acknowledged R1’s and R2’s treatment plans did not include the behavioral health services to be provided to the residents. Technical assistance was provided on this Rule during the during the on-site compliance inspection conducted on February 24, 2023. Date permanent correction will be complete 2024-06-30 Monitoring

Rule: A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that:

4. Includes: d. The date when the resident’s treatment plan will be reviewed;
Evidence: Based on record review and interview, the administrator failed to ensure a treatment plan for each resident included the date the treatment plan was to be reviewed, for two of two residents sampled. The deficient practice posed a risk as treatment plans reinforce and clarify services to be provided to a resident.

Findings:

1. A review of R1’s (admitted in 2023) medical record revealed a treatment plan (dated in 2023). However, the treatment plan did not include the date the treatment plan was to be reviewed.

2. A review of R2’s (admitted in 2024) medical record revealed a treatment plan (dated in 2024). However, the treatment plan did not include the date the treatment plan was to be reviewed.

3. In an interview, E1 acknowledged R1’s and R2’s treatment plans did not include the date the treatment plans were to be reviewed. Date permanent correction will be complete: 2024-06-30

Rule: A. An administrator shall ensure that:

4. Behavioral health services are provided to meet the needs of a resident and are consistent with a behavioral health residential facility’s scope of services;
Evidence: Based on documentation review, record review, and interview, the administrator failed to ensure behavioral health services were consistent with a behavioral health residential facility’s scope of services. The deficient practice posed a risk as the resident was expected to receive medication administration and the facility’s scope of services did not include medication administration. Findings include: R9-10-101.24. “Assistance in the self- administration of medication” means restricting a patient’s access to the patient’s medication and providing support to the patient while the patient takes the medication to ensure that the medication is taken as ordered. R9-10-101.135. “Medication administration” means restricting a patient’s access to the patient’s medication and providing the medication to the patient or applying the medication to the patient’s body, as ordered by a medical practitioner.

2. A review of facility documentation revealed a policy and procedure titled “Section 16: Medication Services” (date unavailable). The policy and procedure stated ” . Although only residents may touch the medications, all staff must was their hands . Staff members should sit at a table with the resident’s medication container/bottle/package on table. . Staff members checks the resident’s medi-set or printed bottle for resident’s name, mg, and number of tabs, to be observed at that time. Staff members asks the resident hot many tabs he/she is to take. . Resident then puts the correct number of tabs into his/her hand or cup and shows staff. . Resident should administer the medication while staff member observes. Resident closes the prescription bottle or medi-set and hands it back to the staff member.” However, policies and procedures to cover administering medication was not available for review.

3. A review of R1’s (admitted in 2023) medical record revealed a treatment plan (dated in 2023). However, R1’s treatment plan did not include whether medication administration or assistance in the self-administration of medication was to be provided to R1 .

4. A review of R2’s (admitted in 2024) medical record revealed a treatment plan (dated in 2024). However, R2’s treatment plan did not include whether medication administration or assistance in the self- administration of medication was to be provided to R2 .

5. In an interview, E1 reported medication administration was provided to R1, R2, and all residents by prepping the medications and placing the medications in a cup, and handing the cup to the residents.

6. In an interview, E1 acknowledged services provided were not consistent with a behavioral health residential facility’s scope of services. Date permanent correction will be complete: 2024-06-30

Findings:

Complaint on 4/14/2025

No violations noted.

Compliance (Annual) on 2/24/2023

Rule: 36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition A. Each health care institution shall develop and administer a training program for all staff regarding fall prevention and fall recovery. The training program shall include initial training and continued competency training in fall prevention and fall recovery. A health care institution may use information and training materials from the department’s Arizona falls prevention coalition in developing the training program.
Evidence: Based on documentation review, record review, and interview, the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not available during the inspection, and the documentation was not provided within two hours after a Department request.

Findings:

1. A review of facility documentation revealed a fall prevention and fall recovery training program was not available for review.

2. A review of E1’s, E2’s, E3’s, E5’s, E6’s, and E7’s personnel records revealed initial training and continued competency training in fall prevention and fall recovery was not available for review.

3. In an interview, E5 reported E5 had worked at BH6807 for approximately two months. E5 reported E5 had not received initial training in fall prevention and fall recovery.

4. In an interview, E1 acknowledged a training program for all staff regarding fall prevention and fall recovery was not developed and administered. Date permanent correction will be complete: 2023-07-01

Rule: C. An administrator shall ensure that:

5. Unless otherwise stated: a. Documentation required by this Article is provided to the Department within two hours after a Department request; and
Evidence: Based on documentation review and interview, the administrator failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request. The deficient practice posed as risk as the Department was unable to determine substantial compliance.

Findings:

1. The Compliance Officer requested, at 10:45AM, the following documentation to be provided to the Department: -Documentation of compliance with the requirements for behavioral health technicians (BHT) in R9-10-115.4; -E2’s complete personnel record to include documentation of a completed orientation, and compliance with the requirements in A.R.S. \’a7\’a7 36-425.03(E)(G); -E3’s complete personnel record to include documentation of a completed orientation and compliance with the requirements in A.R.S. \’a7\’a7 36- 425.03(E); -E5’s complete personnel record to include documentation of clinical oversight; – E7’s complete personnel record to include documentation of compliance with the requirements in A.R.S. \’a7\’a7 36-425.03(E) and clinical oversight; -R1’s and R2’s complete medical records to include documentation of R1’s and R2’s review and update of R1’s and R2’s assessment information; R1’s and R2’s medical history and physical examinations or nursing assessments within 30 calendar days before admission or within 72 hours after admission; and -Fall prevention and fall recovery training program for all staff. However, the documentation was not provided for review within two hours after a Department request.

2. In an interview, E1 acknowledged documentation required by Article 7 was not provided to the Department within two hours after a Department request. Date permanent correction will be complete: 2023-02-25

Rule: C. An administrator shall comply with the requirements for behavioral health technicians and behavioral health paraprofessionals in R9- 10-115.
Evidence: Based on documentation review, record review, and interview, the administrator failed to comply with the requirements for behavioral health technicians (BHT) in R9-10- 115.4. The deficient practice posed a risk to the health and safety of residents if BHTs provided clinical services they were not licensed to provide without clinical oversight by a licensed behavioral health professional (BHP), the Department was unable to determine substantial compliance as the documentation was not available during the inspection, and the documentation was not provided within two hours after a Department request.

Findings: R9-10-115.4. A behavioral health technician receives clinical oversight at least once during each two week period, if the behavioral health technician provides services related to patient care at the health care institution during the two week period.

1. A review of the facility’s policies and procedures revealed a policy titled “Clinical Oversight” (date unavailable). The policy stated ” . Behavioral Health Technicians and Behavioral Health Paraprofessionals providing behavioral health services (counseling, treatment plans and assessments) directly to residents are required to attend a minimum of one (1.) hour of clinical oversight at least once in every two- week period.”

2. A review of facility documentation revealed a packet of worksheets completed by residents, to include R1. The packet of worksheets included a sticky note (dated January 25, year unavailable). The document stated “Group Done by [E5].”

3. A review of facility documentation revealed a packet of worksheets completed by residents, to include R1. The packet of worksheets included a cover page (dated February 1, 2023). The document stated “Small Group ‘How I Feel’.” The document was signed by E5.

4. A review of facility documentation revealed a packet of worksheets completed by residents. The packet of worksheets included a cover page (dated February 8, 2023). The document stated “Wednesday Group ‘Peer Pressure’.” The document was signed by E5.

5. A review of facility documentation revealed a packet of worksheets completed by residents. The packet of worksheets included a cover page (dated February 15, 2023). The document stated “Wednesday Group ‘Coping’.” The document was signed by E5.

6. A review of facility documentation revealed a packet of worksheets completed by residents, to include R1 and R2. The packet of worksheets included a cover page (dated February 23, 2023). The document stated “Reacting to Inner Feelings.” The document was signed by E5. 7. A review of E5’s (hired in 2023) personnel record revealed E5 was hired as a BHT. However, documentation of clinical oversight was not available for review. 8. In an interview, E5 reported E5 conducted group counseling with the residents once a week. 9. In an interview, E1 reported E5 did not receive clinical oversight. 10. A review of R2’s medical record revealed documentation of counseling sessions for the following dates: -February 4, 2023; – February 11, 2023; and -February 18, 2023. The counseling sessions were signed and dated by E7 11. A review of E7’s (hired in 2023) personnel record revealed E7 was hired as a BHT. However, documentation of clinical oversight was not available for review. 12. A review of facility documentation revealed a document titled “Training – Clinically Focused Supervision” (dated February 23, 2023). However, the document did not indicate which BHTs received clinical oversight. 13. In an interview, E1 reported the clinical oversight dated February 23, 2023 was the only clinical oversight for the month of February. 14. In an interview, E1 reported the facility’s BHP, E2, provided clinical oversight once a month. 15. In an interview, E1 acknowledged E5 and E7 did not receive clinical oversight at least once during each two week period. Date permanent correction will be complete: 2023-03-01

Rule: G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes:

3. Documentation of: c. The individual’s completed orientation and in- service education as required by policies and procedures;
Evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of the individual’s completed orientation as required by policies and procedures, for two of seven personnel records sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not in the personnel records during the inspection, and the documentation was not provided within two hours after a Department request.

1. A review of the facility’s policies and procedures revealed a policy titled “Personnel Orientation” (date unavailable). The policy stated “New personnel and temporary personnel must complete orientation prior to working with residents. Each of the items on the personnel orientation form must be completed and initialed by the new personnel and the qualified personnel providing the orientation items. The completed orientation form will become a permanent record in the personnel’s file.”

2. A review of E2’s (hired in 2023) personnel record revealed E2 was hired as the behavioral health professional (BHP). However, documentation of E2’s completed orientation was not available for review.

3. In an interview, E1 reported E2 had not completed orientation.

4. A review of E3’s (hired in 2021) personnel record revealed E3 was hired as the registered nurse. However, documentation of E3’s completed orientation was not available for review.

5. In an interview, E1 reported acknowledged E2’s and E3’s personnel records were not maintained to include documentation of completed orientation. Date permanent correction will be complete: 2023-03-01

Rule: G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes:

3. Documentation of: e. The individual’s compliance with requirements in A.R.S. §§ 36-411, 36-411.01, and 36-425.03, as applicable;
Evidence: Based on record review and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of compliance with the requirements in A.R.S. \’a7\’a7 36-425.03(E)(G), for three of seven personnel records sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not in the personnel records during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: A.R.S. \’a7 36-425.03(E) states “Children’s behavioral health program personnel shall certify on forms that are provided by the department and notarized that they are not awaiting trial on or have never been convicted of or admitted in open court or pursuant to a plea agreement to committing any of the offenses listed in section 41- 1758.03, subsection B or C in this state or similar offenses in another state or jurisdiction.” A.R.S. \’a7 36-425.03(G) states “Employers of children’s behavioral health program personnel shall make documented, good faith efforts to contact previous employers of children’s behavioral health program personnel to obtain information or recommendations that may be relevant to an individual’s fitness for employment in a children’s behavioral health program.

1. A review of E2’s (hired in 2023) personnel record revealed E2 was hired as the behavioral health professional. E2’s personnel record revealed a valid fingerprint clearance card. However, documentation of compliance with A.R.S. \’a7 36-425.03(E)(G) was not available for review.

2. In an interview, E1 reported E2’s personnel record did not include documentation of compliance with A.R.S. \’a7 36-425.03(E)(G).

3. A review of E3’s (hired in 2021) personnel record revealed E3 was hired as the registered nurse. E3’s personnel record revealed a valid fingerprint clearance card. However, documentation of compliance with A.R.S. \’a7 36-425.03(E) was not available for review. 4 A review of E7’s (hired in 2023) personnel record revealed E7 was hired as a behavioral health technician (BHT). E7’s personnel record revealed a valid fingerprint clearance card. However, documentation of compliance with A.R.S. \’a7 36-425.03(E) was not available for review.

5. In an interview, E1 acknowledged E2’s, E3’s, and E7’s personnel records were not maintained to include documentation of compliance with the requirements in A.R.S. \’a7\’a7 36-425.03(E)(G). Date permanent correction will be complete: 2023-05-24

Findings:

Rule: G. An administrator shall ensure that a personnel record is maintained for each
Evidence: Based on documentation review, record review, and interview, the administrator failed personnel member, employee, volunteer, or student that includes:

3. Documentation of: g. If the individual is a behavioral health technician, clinical oversight required in R9-10-115; to ensure a personnel record was maintained for each personnel member to include documentation of clinical oversight required in R9-10-115, for two of two behavioral health technicians (BHT) sampled. The deficient practice posed a risk as clinical oversight could not be verified, the Department was unable to determine substantial compliance as the documentation was not in the personnel records during the inspection, and the documentation was not provided within two hours after a Department request. Findings include:

6. A review of facility documentation revealed a packet of worksheets completed by residents to include R1 and R2. The packet of worksheets included a cover page (dated February 23, 2023). The document stated “Reacting to Inner Feelings’.” The document was signed by E5. 7. A review of E5’s (hired in 2023) personnel record revealed E5 was hired as a BHT. However, documentation of clinical oversight was not available for review. 8. In an interview, E5 reported E5 conducted group counseling with the residents once a week. 9. In an interview, E1 reported E5 did not receive clinical oversight. 10. A review of R2’s medical record revealed documentation of counseling sessions for the following dates: -February 4, 2023; – February 11, 2023; and -February 18, 2023. The counseling sessions were signed and dated by E7 11. A review of E7’s (hired in 2023) personnel record revealed E7 was hired as a BHT. However, documentation of clinical oversight was not available for review. 12. A review of facility documentation revealed a document titled “Training – Clinically Focused Supervision” (dated February 23, 2023). However, the document did not indicate which BHTs received clinical oversight. 13. In an interview, E1 reported the clinical oversight dated February 23, 2023 was the only clinical oversight available for review 14. In an interview, E1 reported the facility’s behavioral health professional (BHP), E2, provided clinical oversight once a month. 15. In an interview, E1 acknowledged E5’s and E7’s personnel records were not maintained to include documentation of clinical oversight required in R9-10-115. Date permanent correction will be complete: 2023-03-01

Findings:

Rule: A. An administrator shall ensure that: 7. If a medical practitioner performs a medical history and physical examination or a nurse performs a nursing assessment on a resident before admission, the medical practitioner enters an interval note or the nurse enters a progress note
Evidence: Based on record review and interview, the administrator failed to ensure if a medical practitioner performed a medical history and physical examination or a nurse performed a nursing assessment on a resident before admission, the medical practitioner entered an in the resident’s medical record within seven calendar days after admission; interval note or the nurse entered a progress note in the resident’s medical record within seven calendar days after admission, for two of two medical records sampled. The deficient practice posed a risk as this information was required for the development and implementation of a treatment plan, per R9- 10-708.A.1., the Department was unable to determine substantial compliance as the documentation was not in the medical records during the inspection, and the documentation was not provided within two hours after a Department request.

Findings:

1. A review of R1’s and R2’s medical records revealed a medical history and physical examination or nursing assessment (per R9-10- 707(A)(6)) was not available for review.

2. In an interview, E1 reported a full physical was performed on R1 and R2 upon admission by a medical practitioner with a third-party provider.

3. In an interview, E1 reported E1 would have to request the aforementioned documentation from the third-party provider, however, the documentation would not be provided within two hours.

4. In an interview, E1 acknowledged if a medical practitioner performed a medical history and physical examination or a nurse performed a nursing assessment on a resident before admission, the medical practitioner entered an interval note or the nurse entered a progress note in R1’s and R2’s medical records within seven calendar days after admission Date permanent correction will be complete: 2023-04-11

Rule: A. An administrator shall ensure that: 10. If a
Evidence: Based on record review and interview, the behavioral health assessment that complies with the requirements in this Section is received from a behavioral health provider other than the behavioral health residential facility or if the behavioral health residential facility has a medical record for the resident that contains a behavioral health assessment that was completed within 12 months before the date of the resident’s current admission: b. The review and update of the resident’s assessment information is documented in the resident’s medical record within 48 hours after the review is completed; administrator failed to ensure a behavioral health assessment in compliance with the requirements in this Section, received from a behavioral health provider other than the behavioral health residential facility, was reviewed, updated, and documented in the resident’s medical record within 48 hours after the review was completed, for two of two residents sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not in the medical records during the inspection, and the documentation was not provided within two hours after a Department request.

Findings:

1. A review of R1’s medical record revealed behavioral health assessments (dated October 11, 2022 and November 4, 2022) from a behavioral health provider other than BH6807. However, documentation of a review and update of R1’s assessment information was not available for review.

2. A review of R2’s medical record revealed a behavioral health assessment (dated July 26, 2022 and January 2, 2023) from a behavioral health provider other than BH6807. However, documentation of a review and update of R2’s assessment information was not available for review.

3. In an interview, E1 reported R1’s and R2’s behavioral health assessments were reviewed by E2; however, E2 did not document the review and update within 48 hours after the review was completed.

4. In an interview, E1 acknowledged the review and update of R1’s and R2’s assessment information was not documented in the residents’ medical record within 48 hours after the reviews were completed. Date permanent correction will be complete: 2023-04-11

Rule: C. An administrator shall ensure that a resident’s medical record contains: 11. Assessment;
Evidence: Based on record review and interview, the administrator failed to ensure a resident’s medical record contained an assessment, for two of two medical records sampled. The deficient practice posed a risk as this information was required for the development and implementation of a treatment plan, per R9-10-708.A.1., the Department was unable to determine substantial compliance as the documentation was not in the medical records during the inspection, and the documentation was not provided within two hours after a Department request.

Findings:

1. A review of R1’s and R2’s medical records revealed a medical history and physical examination or nursing assessment (per R9-10- 707(A)(6)) was not available for review.

2. In an interview, E1 reported a full physical was performed on R1 and R2 upon admission by a medical practitioner with a third-party provider.

3. In an interview, E1 reported E1 would have to request the aforementioned documentation from the third-party provider, however, the documentation would not be provided within two hours.

4. In an interview, E1 acknowledged R1’s and R2’s medical records did not a medical history and physical examination or nursing assessment (per R9-10- 707(A)(6)). Date permanent correction will be complete: 2023-04-11

Complaint on 11/21/2024

No violations noted.

ADVANCED BEHAVIORAL HEALTH LLC
25786 North Desert Mesa Drive, Surprise, AZ 85387

Compliance (Initial) on 1/15/2025 – 2/13/2025

No violations noted.

Compliance (Initial) on 1/15/2025 – 2/13/2025

No violations noted.

ALL ABOUT KIDS
2510 East Yellowstone Place, Chandler, AZ 85249

Compliance (Annual) on 8/7/2024

Rule: 36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition A. Each health care institution shall develop and administer a training program for all staff regarding fall prevention and fall recovery. The training program shall include initial training and continued competency training in fall prevention and fall recovery. A health care institution may use information and training materials from the department’s Arizona falls prevention coalition in developing the training program.
Evidence: Based on documentation review, record review, and interview, the health care institution failed to develop a training program for all staff regarding fall prevention and fall recovery to include initial training and continued competency training. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not developed.

Findings:

1. A review of the facility’s electronic policies and procedures revealed a policy titled “Fall Prevention and Recovery training” (dated November 20, 2023). The policy stated “.Review Arizona Fall Prevention Coalition website for updated information. Review and discuss attached ‘Fall Prevention Checklist for Children.’ Review and discuss ‘Know when and where to get help?’ Make the Home Safe Most falls happen at home.” However, the policy did not include the initial and continued competency training.

2. In an interview, E1 acknowledged a training program was not developed to include initial and continued competency training. Plan of Correction Name, title and/or Position of the Person Responsible Date temporary correction was implemented Date permanent correction will be complete 2024-09-20

Rule: A. An administrator shall ensure that:

6. Except as provided in subsection (E)(1)(a), a medical practitioner performs a medical history and physical examination or a registered nurse performs a nursing assessment on a resident within 30 calendar days before admission or within 72 hours after admission and documents the medical history and physical examination or nursing assessment in the resident’s medical record within 72 hours after admission;
Evidence: Based on record review and interview, the administrator failed to ensure a medical practitioner performed a medical history and physical examination or a registered nurse performed a nursing assessment on a resident within 30 calendar days before admission or within 72 hours after admission, for one of two current residents sampled. The deficient practice posed a risk as this information was required for the development and implementation of a treatment plan, per R9- 10-708.A.1.

Findings:

1. A review of R1’s (admitted in October 2023) medical record revealed documentation to indicate a medical history and physical examination or nursing assessment was completed within 30 calendar days before admission or within 72 hours after admission was not available for review.

2. In an interview, E1 acknowledged a medical history and physical exam or a nursing assessment for R1 was not available for review. Date permanent correction will be complete: 2024-09-20

Rule: A. An administrator shall ensure that: 13. Except
Evidence: Based on record review and interview, the as provided in subsection (E)(1)(d), a resident provides evidence of freedom from infectious tuberculosis: a. Before or within seven calendar days after the resident’s admission, and b. As specified in R9-10-113. administrator failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident’s admission, and as specified in R9-10-113(A)(2), for two of two current residents sampled. The deficient practice posed a TB exposure risk to residents.

Findings: R9-10-113.A.2.a.(i-iii) If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution’s chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that: Include: For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, baseline screening, on or before the date specified in the applicable Article of this Chapter, that consists of: Assessing risks of prior exposure to infectious tuberculosis, Determining if the individual has signs or symptoms of tuberculosis, and Obtaining documentation of the individual’s freedom from infectious tuberculosis according to subsection (B)(1);

1. A review of R1’s and R2’s (both admitted in 2024) medical records revealed baseline screenings were not available for review.

2. A review of R1’s medical record revealed a document from “River People Health Center” (dated October 2023). The document stated “.I ordered lab testing as requested for [R1], who is a resident in your group home. The test result is NEGATIVE for TB.” However, documentation of evidence from infectious TB as specified in R9-10-113 was not available for review.

3. In an interview, E1 acknowledged the administrator failed to ensure R1 and R2 provided evidence of freedom from infectious TB before or within seven calendar days after the resident’s admission, and as specified in R9-10-113(A)(2). Plan of Correction Name, title and/or Position of the Person Responsible Date temporary correction was implemented Date permanent correction will be complete 2024-09-20

Rule: B. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that:

Findings:

1. A review of Department documentation revealed the facility’s license was effective July 7, 2008.

2. A review of facility documentation revealed a daily staffing schedule for August 2024. The daily staffing schedule revealed the facility maintained two shifts: -9:00 AM to 9:00 PM; and -9:00 PM to 9:00 AM.

3. A review of the facility’s documentation revealed disaster drills conducted on the follow dates and times: -January 21, 2024 at 9:30PM; -February 5, 2024 at 9:30PM; -March 25, 2024 at 9:30PM; – April 23, 2024 at 9:30PM; -May 14, 2024 at 9:30PM; and -June 30, 2024 at 9:30PM. However, documentation of disaster drills conducted on the 9:00 AM to 9:00 PM shift were not available for review.

4. In an interview, E1 acknowledged disaster drills for employees were not conducted on each shift. Date permanent correction will be complete: 2024-09-20

Rule: B. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that:

Findings:

1. A review of Department documentation revealed the facility’s license was effective July 7, 2008.

3. A review of the facility’s documentation revealed evacuation drills conducted on the follow dates and times: -January 15, 2024 at 9:30PM; -February 12, 2024 at 9:30PM; -March 20, 2024 at 9:30PM; – April 14, 2024 at 9:30PM; -May 26, 2024 at 9:30PM; -June 23, 2024 at 9:30PM; and -July 31, 2024 at 9:30PM. However, documentation of evacuation drills conducted on the 9:00 AM to 9:00 PM shift were not available for review.

4. In an interview, E1 acknowledged evacuation drills for employees and residents were not conducted on each shift. Date permanent correction will be complete: 2024-09-20

Complaint on 8/7/2024

Rule: C. An administrator shall ensure that:

Findings:

1. The Compliance Officer requested to review the review of the facility’s disaster plan per R9- 10-720.B.3 at 12:30 PM.

2. A review of facility documentation revealed an undated disaster plan. However, documentation to indicate the disaster plan was reviewed at least once every 12 months was not available for review.

3. In an interview, E1 reported the facility’s disaster plan had been reviewed at least once within the last 12 months but was unable to locate the documentation.

4. In an interview, E1 acknowledged documentation required by Article 7 was not provided to the Department within two hours after a Department request. Date permanent correction will be complete: 2024-09-20

Rule: I. If an administrator has a reasonable basis, according to A.R.S. § 13-3620 or 46-454, to believe abuse, neglect, or exploitation has occurred on the premises or while a resident is receiving services from a behavioral health residential facility’s employee or personnel member, the 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 resident: a. For a resident 18 years of age or older, according to A.R.S. § 46-454; or b. For a resident 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 (I)(1); and c. The report in subsection (I)(2);

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

Findings:

Rule: F. An administrator shall ensure that a personnel member, or an employee, a volunteer, or a student who has or is expected to have more than eight hours of direct interaction per week with residents, provides
Evidence: of freedom from infectious tuberculosis:

1. On or before the date the individual begins providing services at or on behalf of the behavioral health residential facility, and

2. As specified in R9-10-113. Evidence Date permanent correction will be complete: 2024-02-14

Findings:

Rule: G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes:

3. Documentation of: h. Cardiopulmonary resuscitation training, if required for the individual according to R9-10- 703(C)(1)(e);
Evidence: Date permanent correction will be complete: 2024-02-14

Findings:

Complaint on 8/7/2024

Rule: G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes:

3. Documentation of: h. Cardiopulmonary resuscitation training, if required for the individual according to R9-10- 703(C)(1)(e);
Evidence: Date permanent correction will be complete: 2024-08-14

Findings:

Rule: J. An administrator shall ensure that the following personnel members have first-aid and cardiopulmonary resuscitation training specific to the populations served by the behavioral health residential facility:

1. At least one
Evidence: personnel member who is present at the behavioral health residential facility during hours of operation of the behavioral health residential facility, and Date permanent correction will be complete: 2024-08-14

Findings:

Rule: G. An administrator shall ensure that a discharge summary for a resident:

Findings:

Rule: A. An administrator shall ensure that:

Findings:

Rule: B. An administrator shall ensure that counseling is:

2. Provided according to the frequency and number of hours identified in the resident’s treatment plan, and
Evidence: Date permanent correction will be complete: 2024-08-14

Findings:

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

Findings:

Rule: B. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that:

Findings:

1. The Compliance Officer requested to review the review of the facility’s disaster plan per R9- 10-720.B.3 at 12:30 PM.

2. A review of facility documentation revealed an undated disaster plan. However, documentation to indicate the disaster plan was reviewed at least once every 12 months was not available for review.

3. In an interview, E1 reported the facility’s disaster plan had been reviewed at least once within the last 12 months but was unable to locate the documentation. Date permanent correction will be complete: 2024-09-20

Complaint;Compliance (Annual) on 8/3/2023

Rule: G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes:

3. Documentation of: h. Cardiopulmonary resuscitation training, if required for the individual according to R9-10- 703(C)(1)(e);
Evidence: Based on record review and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of cardiopulmonary resuscitation (CPR) training, for one of ten personnel members sampled. The deficient practice posed a risk if E5 was unable to perform CPR.

Findings:

1. A review of E5’s (hired in 2023) personnel record revealed E5 was hired as the registered nurse and documentation of current Basic Life support (BLS) training dated September 21, 2021. However, documentation of CPR was not available for review.

2. In a joint interview, E1 and E2 acknowledged E5’s personnel record did not include documentation of current CPR training. Date permanent correction will be complete: 2024-08-14

1. At least one personnel member who is present at the behavioral health residential facility during hours of operation of the behavioral health residential facility, and
Evidence: Based on observation, record review, and interview, the administrator failed to ensure at least one personnel member was present at the behavioral health residential facility during hours of operation who had cardiopulmonary resuscitation (CPR) training specific to the populations served. The deficient practice posed a risk if an employee was unable to meet a resident’s needs during an emergency or an accident.

Findings:

1. The Compliance Officer Observed E2 on the premises and working alone when the Compliance Officer arrived at approximately 9:00AM.

2. The Compliance Officer observed five residents on the premises.

3. A review of E2’s personnel record revealed documentation of CPR and first aid training from Heartsaver, issued on May 7, 2023 with an expiration date of May 2025. However, documentation to indicate the CPR training was specific to the population served was not available for review.

4. A review of facility documentation revealed a daily staffing schedule for July 1-31, 2023. The daily staffing schedule revealed E2 was scheduled to work alone on the following dates and times: – July 9-10, 2023 9:00AM-9:00PM.

5. A review of E3’s personnel record revealed documentation of CPR and AED training from Heartsaver, issued on February 8, 2022 with an expiration date of February 2024. However, documentation to indicate the CPR training was specific to the population served was not available for review.

6. A review of facility documentation revealed a daily staffing schedule for June 1-30, 2023. The daily staffing schedule revealed E3 was scheduled to work alone on the following dates and times: – Every Thursday 9:00PM-9:00AM. 7. A review of E6’s personnel record revealed documentation of adult CPR and first aid training from HSI, issued on May 19, 2023 with an expiration date of May 2025. However, the CPR training was not specific to the population served. 8. A review of E8’s personnel record revealed documentation of adult CPR and first aid training from HSI, issued on May 8, 2023 with an expiration date of May 2025. However, the CPR training was not specific to the population served. 9. A review of E9’s personnel record revealed documentation of adult CPR and first aid training from HSI, issued on February 6, 2023 with an expiration date of February 2025. However, the CPR training was not specific to the population served. 10. A review of E10’s personnel record revealed documentation of adult CPR and first aid training from HSI, issued on January 17, 2023 with an expiration date of January 2025. However, the CPR training was not specific to the population served. 11. A review of facility documentation revealed a daily staffing schedule for July 1-31, 2023. The daily staffing schedule revealed E10 was scheduled to work alone on the following dates and times: -July 2- 5, 2023 9:00PM-9:00AM; -July 9-12, 2023 9:00PM-9:00AM; -July 16-19, 2023 9:00PM- 9:00AM; -July 23-26, 2023 9:00PM-9:00AM; and -July 30-31, 2023 9:00PM-9:00AM. 12. In a joint interview, E1 and E2 acknowledged at least one personnel member was not present at the behavioral health facility during hours of operation who had CPR training specific to children. Date permanent correction will be complete: 2024-08-14

Rule: G. An administrator shall ensure that a discharge summary for a resident:

2. Includes: a. The following information authenticated by a medical practitioner or a behavioral health professional: i. The resident’s presenting issue and other physical health and behavioral health issues identified in the resident’s treatment plan; ii. A summary of the treatment provided to the resident; iii. The resident’s progress in meeting treatment goals, including treatment goals that were and were not achieved; and iv. The name, dosage, and frequency of each medication ordered for the resident by a medical practitioner at the behavioral health residential facility at the time of the resident’s discharge;
Evidence: Based on record review and interview, the administrator failed to ensure a discharge summary for a resident was authenticated by a medical practitioner or behavioral health professional (BHP), for one of two discharged residents sampled.

Findings: R9-10- 101(26) “Authenticate” means to establish authorship of a document or an entry in a medical record by: a. A written signature; b. An individual’s initials, if the individual’s written signature appears on the document or in the medical record; c. A rubber-stamp signature; or d. An electronic signature code.

1. A review of R1’s medical record revealed a discharge summary. The document contained the requirements for a discharge summary, however, the document was not authenticated by a medical practitioner or BHP.

2. In a joint interview, E1 and E2 acknowledged R1’s discharge summary was not authenticated by a medical practitioner or BHP. Date permanent correction will be complete: 2024-08-14

Rule: A. An administrator shall ensure that:

2. If a behavioral health residential facility is licensed to provide behavioral health services to individuals whose behavioral health issue limits the individuals’ ability to function independently, a resident admitted to the behavioral health residential facility with limited ability to function independently receives: b. Continuous protective oversight;
Evidence: Based on record review and interview, the administrator failed to ensure a behavioral health residential facility licensed to provide behavioral health services to individuals whose behavioral health issue limits the individuals’ ability to function independently, a resident admitted to the behavioral health residential facility with limited ability to function independently received continuous protective oversight. The deficient practice posed a risk as residents did not receive continuous protective oversight.

Findings:

1. A review of R2’s medical record revealed an Incident Report (dated May 2023). The document stated “.Therapist observed from a camera monitor, [R2] sitting on couch next to.[R3] and appeared to quickly remove [R2’s] hand left hand from [R3’s] lap area.[R2] disclosed that today was not the first time [R2] has engaged in sexually inappropriate behavior with [R3]; [R2] disclosed this has happened multiple times before today but did not give details, number of frequency unknown.”

2. In a joint interview, E1 and E2 acknowledged the minor residents did not receive continuous protective oversight as personnel members were not present during the incident. Date permanent correction will be complete: 2024-08-14

Rule: B. An administrator shall ensure that counseling is:

2. Provided according to the frequency and number of hours identified in the resident’s treatment plan, and
Evidence: Based on record review and interview, the administrator failed to ensure counseling was provided according to the number of hours in the resident’s treatment plan, for two of two current residents and two of two discharged residents sampled. The deficient practice posed a risk if a resident did not receive treatment to cure, improve, or palliate their behavioral health issue at the health care institution.

Findings:

1. A review of R1’s medical record revealed a treatment plan (dated in May 2023). The treatment plan stated “.Attend groups to learn effective communication and coping skills to increase healthy interaction and communication.1 to 3x’s weekly 2-3 hrs weekly.”

2. A review of R1’s medical record revealed group counseling on the following dates: -June 6, 2023 for 1 hour; -June 7, 2023 for 1 hour; -June 13, 2023 for 1 hour; -June 20, 2023 for 1 hour; -June 21, 2023 for 1 hour; -June 28, 2023 for 1 hour; and -July 5, 2023 for 1 hour. -July 22, 2023 for 1 hour. However, documentation to indicate R1 received group counseling according to the number of hours identified in R1’s treatment plan was not available for review.

3. A review of R2’s medical record revealed a treatment plan (dated in February 2023). The treatment plan stated “.Attend groups to learn effective communication and coping skills to increase healthy interaction and communication.1 to 3x’s weekly 2-3 hrs weekly.”

4. A review of R2’s medical record revealed group counseling on the following dates: -April 17, 2023 for 1 hour; -April 24, 2023 for 1 hour; -April 25, 2023 for 1 hour; -June 27, 2023 for 1 hour; and -May 1, 2023 for 1 hour. However, documentation to indicate R2 received group counseling according to the number of hours identified in R2’s treatment plan was not available for review.

5. A review of R3’s medical record revealed a treatment plan (dated in June 2023). The treatment plan stated “.Attend groups to learn effective communication and coping skills to increase healthy interaction and communication.1 to 3x’s weekly 2-3 hrs weekly.”

6. A review of R3’s medical record revealed group counseling on the following dates: -June 29, 2023 for 1 hour; -July 5, 2023 for 1 hour; -July 11, 2023 for 1 hour; -July 12, 2023 for 1 hour; -July 18, 2023 for 1 hour; and -July 20, 2023 for 1 hour. -July 5, 2023 for 1 hour. However, documentation to indicate R3 received group counseling according to the number of hours identified in R3’s treatment plan was not available for review. 7. A review of R4’s medical record revealed a treatment plan (dated in June 2023). The treatment plan stated “.Attend groups to learn effective communication and coping skills to increase healthy interaction and communication.1 to 3x’s weekly 2-3 hrs weekly.” 8. A review of R4’s medical record revealed group counseling on the following dates: -July 5, 2023 for 1 hour; -July 11, 2023 for 1 hour; -July 12, 2023 for 1 hour; -July 18, 2023 for 1 hour; and -July 20, 2023 for 1 hour. However, documentation to indicate R4 received group counseling according to the number of hours identified in R4’s treatment plan was not available for review. 9. In a joint interview, E1 and E2 acknowledged counseling was not provided according to the number of hours identified in R1’s, R2’s, R3’s, and R4’s treatment plans. Date permanent correction will be complete: 2024-08-14

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

4. Training for a personnel member, other than a medical practitioner or registered nurse, in assistance in the self-administration of medication: a. Is provided by a medical practitioner or registered nurse or an individual trained by a medical practitioner or registered nurse; and b. Includes: i. A demonstration of the personnel member’s skills and knowledge necessary to provide assistance in the self- administration of medication, ii. Identification of medication errors and medical emergencies related to medication that require emergency medical intervention, and iii. The process for notifying the appropriate entities when an emergency medical intervention is needed;
Evidence: Based on record review and interview, the administrator failed to ensure training in the assistance in the self-administration of medication included a demonstration of the personnel member’s skills and knowledge necessary to provide assistance in the self- administration of medication, identification of medication errors, and medical emergencies related to medication that required emergency medical intervention, and the process for notifying the appropriate entities when an emergency medical intervention was needed, for three of ten personnel members sampled.

Findings:

1. A review of E1’s personnel record revealed a document titled “CERTIFICATE OF COMPLETION.For completion of Medication Assistance Training Course” (dated January 18, 2023). However, the document did not include a demonstration of E1’s skills and knowledge necessary to provide assistance in the self-administration of medication, identification of medication errors, and medical emergencies related to medication that required emergency medical intervention, and the process for notifying the appropriate entities when an emergency medical intervention was needed.

2. A review of E2’s personnel record revealed a document titled “Certificate of Completion THIS ACKNOWLEDGES THAT [E2] HAS SUCCESSFULLY COMPLETED MEDICATION ADMINISTRATION TRAINING” (dated May 18, 2021). However, the document did not include a demonstration of E2’s skills and knowledge necessary to provide assistance in the self-administration of medication, identification of medication errors, and medical emergencies related to medication that required emergency medical intervention, and the process for notifying the appropriate entities when an emergency medical intervention was needed.

3. A review of E10’s personnel record revealed a document titled Certificate of Completion THIS ACKNOWLEDGES THAT [E10] HAS SUCCESSFULLY COMPLETED MEDICATION ADMINISTRATION TRAINING” (dated February 3, 2021). However, the document did not include a demonstration of E10’s skills and knowledge necessary to provide assistance in the self-administration of medication, identification of medication errors, and medical emergencies related to medication that required emergency medical intervention, and the process for notifying the appropriate entities when an emergency medical intervention was needed.

4. In an interview, E1 acknowledged E1, E2, and E10 were not trained in the required components. Date permanent correction will be complete: 2024-08-14

Rule: B. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that:

Findings:

1. A review of facility documentation revealed a disaster plan dated January 2, 2022. However, documentation to indicate the disaster plan was reviewed at least once every 12 months was not available for review.

2. In a joint interview, E1 and E2 acknowledged the facility’s disaster plan had not been reviewed at least once within the last 12 months. Date permanent correction will be complete: 2024-09-20

Complaint on 6/12/2024

No violations noted.

Complaint on 5/14/2024

Rule: A.R.S. § 36-424. Inspections; suspension or revocation of license; report to board of examiners of nursing care institution administrators and assisted living facility managers C. On a determination by the director that there is reasonable cause to believe a health care institution is not adhering to the licensing requirements of this chapter, the director and any duly designated employee or agent of the director, including county health representatives and county or municipal fire inspectors, consistent with standard medical practices, may enter on and into the premises of any health care institution that is licensed or required to be licensed pursuant to this chapter at any reasonable time for the purpose of determining the state of compliance with this chapter, the rules adopted pursuant to this chapter and local fire ordinances or rules. Any application for licensure under this chapter constitutes permission for and complete acquiescence in any entry or inspection of the premises during the pendency of the application and, if licensed, during the term of the license. If an inspection reveals that the health care institution is not adhering to the licensing requirements established pursuant to this chapter, the director may take action authorized by this chapter. Any health care institution, including an accredited hospital, whose license has been suspended or revoked in accordance with this section is subject to inspection on application for relicensure or reinstatement of license.
Evidence: Based on documentation review, observation and interview, the licensee failed to provide complete acquiescence in any entry or inspection of the premises during the term of the license. The deficient practice posed a risk as such action shall be deemed as a reasonable cause to believe a substantial violation exists as the Department was unable to gain entry for 65 minutes.

Findings: A.R.S. \’a7 36- 427(B) If the licensee, the chief administrative officer or any other person in charge of the institution refuses to permit the department or its employees or agents the right to inspect the institution’s premises as provided in section 36-424, such action shall be deemed reasonable cause to believe that a substantial violation under subsection A, paragraph 3 of this section exists.

1. A review of the Department documentation revealed the facility’s perpetual license was effective on July 1, 2020.

2. The Compliance Officer arrived at the facility at 12:30 PM to conduct a complaint inspection. The Compliance Officer rang the door bell and knocked at the door. However, no one answered the door.

3. In a telephonic interview, conducted at 12:30 PM, E1 reported E1 was about an hour away and a personnel member was about 30 to 45 minutes away.

4. In a telephonic interview, conducted at 1:29 PM, E1 reported E1 was approximately 20 minutes away from BH3031.

5. The Compliance Officer observed E2 arrive on the premises at approximately 1:35 PM.

6. In an interview, E1 acknowledged the findings. Date permanent correction will be complete: 2024-07-10

1. On or before the date the individual begins providing services at or on behalf of the behavioral health residential facility, and

2. As specified in R9-10-113. Evidence Based on record review and interview, the administrator failed to ensure a personnel member provided evidence of freedom from infectious tuberculosis (TB), as specified in Arizona Administrative Code (A.A.C.) R9-10- 113(B)(2), for one of four personnel members sampled. The deficient practice posed a TB exposure risk to residents and false or misleading documentation was provided to the Department.

Findings: A.A.C. R9-10- 113(B)(2) A health care institution’s chief administrative officer shall:

2. As part of the annual assessment of the health care institution’s risk of exposure to infectious tuberculosis according to subsection (A)(2)(d), ensure that documentation is obtained for each individual required to be screened for infectious tuberculosis that: a. Indicates the individual’s freedom from symptoms of infectious tuberculosis; and b. Is signed by a medical practitioner, occupation health provider, as defined in A.A.C. R9-6-801, or local health agency, as defined in A.A.C. R9-6-101.

1. A review of E5’s personnel records revealed documented evidence of freedom from infectious TB, dated in April 2022. However, a two-step TB test was not available for review.

2. A review of the evidence of freedom from infectious TB, dated in April 2022, revealed the document appeared altered as the “open date”, the administered date, and “read” date had blue ink written over the year of “22” to indicate the year of “24.”

3. In an interview, E1 acknowledged documented evidence of freedom from infectious TB for E5 was not available for review and false or misleading documentation was provided to the Department. This Rule was cited on January 25, 2024. A letter sent to the facility, dated February 12, 2024, stated “.the Department is not requesting a WRITTEN Plan of Correction (POC) at this time. However, the Department still requires that you make corrections to all violations noted in the SOD. Please document all corrections.” Date permanent correction will be complete: 2024-07-17

Complaint on 4/24/2024

Rule: E. An administrator shall ensure that:

2. Within 24 hours after an emergency safety response is used for a resident, the following information is entered into the resident medical record: a. The date and time the emergency safety response was used; b. The name of each personnel member who used an emergency safety response; c. The specific emergency safety response used; d. The personnel member or resident behavior, event, or environmental factor that caused the need for the emergency safety response; and e. Any injury that resulted from the use of the emergency safety response;
Evidence: Based on record review and interview, the administrator failed to ensure within 24 hours after an emergency safety response (ESR) was used for a resident, the following information was entered into the resident medical record: the date and time the ESR was used, the name of each personnel member who used an ESR, the specific ESR used, and any injury that resulted from the use of the ESR. Findings include:

1. A review of R2’s medical record revealed an incident report dated in January 2024. The incident report stated “.Suddenly client [R2] broke a tree branch from the tree and began to go after the client and hit.several times with the stick. Staff intervened and stopped client [R2] from continuing to physically attack client.[R2] started punching this staff member, kicking and trying to bite staff. For the safety of staff and other clients. [sic] Staff placed client [R2] in a therapeutic hold until client [R2] was able to calm down and show [R2] was not a threat to staff and other clients. Police arrived at the house to assist with the intervention.” However, the time the ESR was used, the name of each personnel member who used an ESR, the specific ESR used, and any injury that resulted from the use of the ESR was not available for review.

2. A review of R3’s medical record revealed an incident report dated in March 2024. The incident report stated “.[R3] began to escelate [sic] and displayed physical aggression toward staff and was placed in a nonviolent therapeutic hold. Client stated [R3] was calm and wanted to sit in [R3’s] room, Staff allowed client to sit in [R3’s] room when [R3] became more agitated. staff then walked to answer the door when staff could hear 2 loud bangs on the wall, Staff returned to check on the client when [R3] banged [R3’s] head against the wall for a 3rd time [R3] was then placed in a therapeutic hold to prevent serious injury.” However, the time the ESR was used, the specific ESR used, and any injury that resulted from the use of the ESR was not available for review.

3. In an interview, E1 acknowledged the required information was not documented related to the ESRs used for each resident. Date permanent correction will be complete: 2024-05-17

Findings:

Compliance (Annual) on 12/27/2022

Rule: A.R.S. § 36-411. Residential care institutions; nursing care institutions; home health agencies; fingerprinting requirements; exemptions; definitions C. Owners shall make documented, good faith efforts to:

2. Verify the current status of a person’s fingerprint clearance card.
Evidence: Based on record review and interview, the owner failed to ensure compliance with A.R.S. \’a7 36-411(C)(1), for four of eight employees sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not in the personnel records during the inspection, and the documentation was not provided within two hours after a Department request.

Findings:

1. A review of E1’s (hired in 2022) personnel record revealed documentation of a reference letter from a previous employer and a previous co-worker reference. However, documentation to meet the requirements of A.R.S. \’a7 36-411(C)(1) was not available for review.

2. A review of E2’s (hired in 2020) personnel record revealed documentation of reference letters from what appeared to be previous employers and a personal reference. However, documentation to meet the requirements of A.R.S. \’a7 36- 411(C)(1) was not available for review.

3. A review of E5’s (hired in 2022) personnel record revealed documentation of compliance with A.R.S. \’a7 36-411(C)(1) was not available for review.

4. A review of E6’s (hired in 2022) personnel record revealed documentation of compliance with A.R.S. \’a7 36-411(C)(1) was not available for review.

5. In an interview, E1 acknowledged documentation of compliance with A.R.S. \’a7 36-411(C)(1) for E1, E2, E5, and E6 was not available for review. Date permanent correction will be complete 2023-01-18 Monitoring

Rule: 36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition A. Each health care institution shall develop and administer a training program for all staff regarding fall prevention and fall recovery. The training program shall include initial training and continued competency training in fall prevention and fall recovery. A health care institution may use information and training materials from the department’s Arizona falls prevention coalition in developing the training program.
Evidence: Based on documentation review, record review and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery to include initial training and continued competency training in fall prevention and fall recovery.

Findings:

1. A review of the facility’s policies and procedures revealed a policy titled “Staff Training and Orientation” (dated November 15, 2022). However, evidence of a fall prevention and fall recovery training program was not available for review.

2. A review of the facility’s policies and procedures revealed three pages of what appeared to be a copy of materials from the Centers for Disease Control and Prevention (CDC). The documents were placed after a policy titled “Administrator Qualifications” (dated November 15, 2022).

3. A review of E5’s, E6’s and E7’s personnel records revealed documentation of initial training or continued competency training in fall prevention and fall recovery was not available for review.

4. In an interview, E1 acknowledged the facility had not developed and administered a training program for all staff regarding fall prevention and fall recovery. Date permanent correction will be complete: 2023-01-18

Rule: B. An administrator:

3. Except as provided in subsection (A)(6), designates, in writing, an individual who is present on the behavioral health residential facility’s premises and accountable for the behavioral health residential facility when the administrator is not present on the behavioral health residential facility’s premises.
Evidence: Based on observation, record review, documentation review, and interview, the administrator failed to designate, in writing, an individual who was present on the behavioral health residential facility’s premises and accountable for the behavioral health residential facility when the administrator was not present on the behavioral health residential facility’s premises. The deficient practice posed a risk as a facility standard was not followed, the designated individual to act on behalf of the governing authority was not present on the facility’s premises when the administrator was not present, the Department was unable to determine substantial compliance as the documentation was not available during the inspection, and the documentation was not provided within two hours after a Department request.

Findings:

1. The Compliance Officer observed E2 on the premises and working alone upon arrival at 9:10 AM.

2. The Compliance Officer observed E1 arrive on the premises at approximately 9:15 AM.

3. In a interview, E2 reported E1 was the day shift personnel member and E1 would assist with the inspection, as E2 was the night shift personnel member.

4. A review of E1’s (hired in 2022) personnel record revealed E1 was hired as a behavioral health technician (BHT). However, documentation designating E1 to be present on the behavioral health residential facility’s premises and accountable for the behavioral health facility when the administrator was not present was not available for review.

5. A review of E2’s (hired in 2020) personnel record revealed E2 was hired as a BHT. However, documentation designating E2 to be present on the behavioral health residential facility’s premises and accountable for the behavioral health facility when the administrator was not present was not available for review.

6. A review of the facility’s policies and procedures revealed a policy titled “Delegation of Authority Policy” (dated February 20, 2021). The policy stated “.Other than as expressly provided in this policy, all matters not specifically reserved for the administration and necessary for the day to day management of the organization and the implementation of day to day functions. Management may sub-delegate where appropriate. The agency’s policies and procedures provide guidance on the execution of specific roles and responsibilities. In the absence of administration, agency employees shall be responsible for.The following staff are delegated to fulfill the above listed responsibilities in the absence of administrator.” However, E1 and E2 were not designated to be present on the behavioral health residential facility’s premises and accountable for the behavioral health residential facility when the administrator was not present on the behavioral health residential facility’s premises 7. A review of the facility’s policies and procedures revealed a policy titled “Delegation of Authority Policy” (dated May 1, 2018 ). The policy stated “.Other than as expressly provided in this policy, all matters not specifically reserved for the administration and necessary for the day to day management of the organization and the implementation of day to day functions. Management may sub-delegate where appropriate. The agency’s policies and procedures provide guidance on the execution of specific roles and responsibilities. In the absence of administration, agency employees shall be responsible for.The following staff are delegated to fulfill the above listed responsibilities in the absence of an administrator.” However, E1 and E2 were not designated to be present on the behavioral health residential facility’s premises and accountable for the behavioral health residential facility when the administrator was not present on the behavioral health residential facility’s premises 8. In an interview, E1 acknowledged an individual was not designated, in writing, to be present on the behavioral health residential facility’s premises and accountable for the behavioral health residential facility when the administrator was not present on the behavioral health residential facility’s premises. Date permanent correction will be complete: 2023-01-15

Rule: C. An administrator shall ensure that:

1. Policies and procedures are established, documented, and implemented to protect the health and safety of a resident that: e. Cover cardiopulmonary resuscitation training including: i. The method and content of cardiopulmonary resuscitation training, which includes a demonstration of the individual’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 individual has received cardiopulmonary resuscitation training;
Evidence: Based on documentation review, record review, and interview, the administrator failed to implement policies and procedures to protect the health and safety of a resident to cover cardiopulmonary resuscitation (CPR) training to include a demonstration of the individual’s ability to perform cardiopulmonary resuscitation. The deficient practice posed a risk as the standards expected of employees were not followed, the Department was unable to determine substantial compliance as the documentation was not in the personnel records during the inspection, and the documentation was not provided within two hours after a Department request. Findings include:

1. A review of the facility’s policies and procedures revealed a policy titled “Staff Member and Employee Qualifications and Records” (November 15, 2022). The policy stated “Agency will ensure that a personnel record is maintained for each staff member that contains.The staff’s member’s documentation of CPR and first aid training, as required in, [sic] if applicable.”

2. A review of the facility’s policies and procedures revealed a policy titled “Cardiopulmonary Resuscitation (CPR)” (November 15, 2022). The policy stated “Existing staff and newly hired employees will provide documentation of cardiopulmonary resuscitation certification to include.Method of CPR training, which includes a live demonstration.The time frame for renewal CPR training; CPR certification must be renewed every 2 years.”

3. A review of E2’s personnel record revealed documentation of CPR and first aid training from NationalCPRFoundation, issued on November 29, 2021 with an expiration date of November 29, 2023.

4. A review of E5’s personnel record revealed documentation of CPR and first aid training from NationalCPRFoundation, issued on September 19, 2022 with an expiration date of September 19, 2024.

5. A review of E7’s personnel record revealed documentation of CPR and first aid training from NationalCPRFoundation, issued on September 15, 2019 with an expiration date of September 15, 2021.

6. A review of the NationalCPRFoundation website revealed courses were conducted online. The NationalCPRFoundation website stated “Help Save Lives Today with Your Online CPR Certification Training!” 7. In an interview, E1 acknowledged E2’s, E5’s, and E7’s CPR training did not include a demonstration of the individual’s ability to perform CPR, E7’s CPR and first aid training had expired, and the policy and procedure was not implemented. Date permanent correction will be complete: 2023-01-17

Findings:

Rule: C. An administrator shall ensure that:

5. Unless otherwise stated: a. Documentation required by this Article is provided to the Department within two hours after a Department request; and
Evidence: Based on record review and interview, the administrator failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the licensee did not provide the following: written designation of an individual; E2’s, E5’s, and E7’s demonstration of cardiopulmonary resuscitation (CPR) training; E3’s current contract; E6’s verification of skills and knowledge; E6’s documentation of completed orientation; R1’s, R2’s, and R3’s updated treatment plans; R1’s, R2’s, and R3’s documentation of counseling per R9-10- 716(C)(2)(b)(e); E1’s assistance in the self- administration of medication training; E1’s, E2’s, E5’s, and E6’s documentation of compliance with A.R.S. \’a7 36-411(C)(1); and E5’s, E6’s, and E7’s fall prevention and fall recovery training.

Findings:

1. A review of facility documentation and personnel records revealed the administrator did not designate, in writing, an individual to be present on the behavioral health residential facility’s premises and accountable for the behavioral health residential facility when the administrator was not present on the behavioral health residential facility’s premises.

2. A review of E2’s personnel record revealed documentation of CPR and first aid training from NationalCPRFoundation, issued on November 29, 2021 with an expiration date of November 29, 2023.

3. A review of E5’s personnel record revealed documentation of CPR and first aid training from NationalCPRFoundation, issued on September 19, 2022 with an expiration date of September 19, 2024.

4. A review of E7’s personnel record revealed documentation of CPR and first aid training from NationalCPRFoundation, issued on September 15, 2019 with an expiration date of September 15, 2021.

5. A review of the NationalCPRFoundation website revealed courses were conducted online. The NationalCPRFoundation website stated “Help Save Lives Today with Your Online CPR Certification Training!”

6. A review of E3’s personnel record revealed E3 was hired as a clinical supervisor. The record revealed documentation of contracted services (dated December 7, 2012). The contract stated “This agreement shall commence on December 7, 2012 and shall expire in one year from this date.” However, documentation of current contracted services was not available for review. 7. A review of E6’s (hired in 2022) personnel record revealed E6 was hired as a therapist. However, documentation to demonstrate E6’s skills and knowledge were verified and documented was not available for review. 8. A review of E6’s (hired in 2022) personnel record revealed documentation of completed orientation was not available for review. 9. A review of R1’s medical record revealed a treatment plan dated in March 2022. The treatment plan included review dates for April 14, 2022, May 14, 2022, and June 14, 2022. The record also revealed a treatment plan dated in June 2022. The treatment plan included a review date for July 11, 2022, August 11, 2022 and September 11, 2022. The record also revealed a treatment plan dated in September 2022 and October 2022. However, updated treatment plans dated in April 2022, May 2022, July 2022, and August 2022 were not available for review. 10. A review of R2’s medical record revealed a treatment plan dated in October 2022. The treatment plan included review dates for November 2022 and December 2022. However, an updated treatment plan dated in November 2022 was not available for review. 11. A review of R3’s medical record revealed a treatment plan dated in January 2022. The treatment plan included review dates for February 28, 2022, March 30, 2022, and April 30, 2022. The record also revealed a treatment plan dated in April 2022. The treatment plan included review dates for May 30, 2022, June 30, 2022, and July 30, 2022. The record also revealed a treatment plan dated in July 2022. The treatment plan included review dates for August 27, 2022, September 27, 2022, and October 27, 2022. The record also revealed a treatment plan dated in October 2022. However, an updated treatment plan dated in February 2022, March 2022, May 2022, June 2022, August 2022, and September 2022 was not available for review. 12. A review of R1’s, R2’s, and R3’s medical records revealed each counseling session was not documented to include the requirements in R9-10-716(C)(2) (b)(e). 13. A review of E1’s personnel record revealed E1 was hired as a behavioral health technician (BHT). However, documentation of completed training in the assistance in the self- administration of medication was not available for review. 14. A review of E1’s (hired in 2022) personnel record revealed documentation of a reference letter from a previous employer and a previous co-worker reference. However, documentation to meet the requirements of A.R.S. \’a7 36-411(C)(1) was not available for review. 15. A review of E2’s (hired in 2020) personnel record revealed documentation of reference letters from what appeared to be previous employers and a personal reference. However, documentation to meet the requirements of A.R.S. \’a7 36-411(C)(1) was not available for review. 16. A review of E5’s (hired in 2022) personnel record revealed documentation of compliance with A.R.S. \’a7 36-411(C)(1) was not available for review. 17. A review of E6’s (hired in 2022) personnel record revealed documentation of compliance with A.R.S. \’a7 36-411(C)(1) was not available for review. 18. A review of E5’s, E6’s and E7’s personnel records revealed documentation of initial training or continued competency training in fall prevention and fall recovery was not available for review. 19. In an interview, E1 acknowledged documentation required by this Article was not provided to the Department within two hours after a Department request. Date permanent correction will be complete: 2023-01-18

Rule: An administrator shall ensure that:

2. Documentation of current contracted services is maintained that includes a description of the contracted services provided.
Evidence: Based on record review, documentation review, and interview, the administrator failed to ensure documentation of current contracted services was maintained. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not in the personnel record during the inspection, and the documentation was not provided within two hours after a Department request.

Findings:

1. A review of E3’s personnel record revealed E3 was hired as a contracted clinical supervisor (BHP). The record revealed documentation of contracted services (dated December 7, 2012). The contract stated “This agreement shall commence on December 7, 2012 and shall expire in one year from this date.” However, documentation of current contracted services was not available for review.

2. A review of the facility’s daily staffing schedule revealed E3 was the on-call BHP.

3. A review of R1’s medical record revealed a group counseling note signed by E3 on the following date: -July 28, 2022.

4. A review of R1’s medical record revealed a treatment plan signed by E3 (dated in September 2022 and October 2022).

5. A review of R3’s medical record revealed a treatment plan signed by E3 (dated in October 2022).

6. In an interview, E1 acknowledged documentation of current contracted services was not available for review. Date permanent correction will be complete: 2023-03-08

Rule: B. An administrator shall ensure that:

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; and
Evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel member’s skills and knowledge were verified and documented before the personnel member provided behavioral health services, and according to policies and procedures, for one of eight personnel members sampled. The deficient practice posed a risk if E6 was unable to meet a residents needs, the Department was unable to determine substantial compliance as the documentation was not in the personnel record during the inspection, and the documentation was not provided within two hours after a Department request. Findings include:

1. A review of the facility’s policies and procedures revealed a policy titled “Staff Member and Employee Qualifications and Records” (November 15, 2022). The policy stated “Verification of Behavioral Health Services within the above knowledge and skills area will be verified either by the By the [sic] clinical director, a behavioral health professional, or a behavioral health technician with a combination of at least six years of education in a field related to behavioral health and fill-time behavioral health work experience.Evidence of being competent within the above knowledge and skill areas; thus, allowing you to work directly with residents will be maintained within your personnel file.”

2. A review of E6’s (hired in 2022) personnel record revealed E6 was hired as a therapist. However, documentation to demonstrate E6’s skills and knowledge were verified and documented was not available for review.

3. A review of R1’s (admitted in 2022) medical record revealed individual and group counseling notes to indicate E6 provided the counseling sessions.

4. A review of R2’s (admitted in 2022) medical record revealed individual and group counseling notes to indicate E6 provided the counseling sessions.

5. A review of R3’s (admitted in 2020) medical record revealed individual and group counseling notes to indicate E6 provided the counseling sessions.

6. In an interview, E1 acknowledged E6’s skills and knowledge were not verified and documented prior to providing behavioral health services and according to policies and procedures. Date permanent correction will be complete: 2023-03-08

Findings:

Rule: G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes:

3. Documentation of: c. The individual’s completed orientation and in-
Evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of the individual’s completed service education as required by policies and procedures; orientation as required by policies and procedures, for one of eight personnel records sampled. The deficient practice posed a risk if E6 was unable to meet a resident’s needs, the Department was unable to determine substantial compliance as the documentation was not in the personnel record during the inspection, and the documentation was not provided within two hours after a Department request.

1. A review of the facility’s policies and procedures revealed a policy titled “Staff Training and Orientation” (November 15, 2022). The policy stated “The program director will provide supervision and monitoring of staff’s interaction with the residents by a way of on site observation. The program director will monitor each staff’s overall performance and feedback will be given to staff as needed.”

2. A review of the facility’s policies and procedures revealed a policy titled “Staff Member and Employee Qualifications and Records” (dated November 15, 2022). The policy stated “Agency will ensure that a personnel record is maintained for each staff member that contains.The staff member’s completion of the orientation required.”

3. A review of E6’s (hired in 2022) personnel record revealed documentation of completed orientation was not available for review.

4. In an interview, E1 acknowledged documentation of E6’s completed orientation as required by policies and procedures was not available for review. Date permanent correction will be complete: 2023-01-18

Rule: A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that:

6. Is reviewed and updated on an on-going basis: a. According to the review date specified in the treatment plan,
Evidence: Based on record review and interview, the administrator failed to ensure a treatment plan for each resident was reviewed and updated on an on-going basis according to the review date specified in the treatment plan, for three of three residents sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not in the medical records during the inspection, and the documentation was not provided within two hours after a Department request.

Findings:

1. A review of R1’s medical record revealed a treatment plan dated in March 2022. The treatment plan included review dates for April 14, 2022, May 14, 2022, and June 14, 2022. The record also revealed a treatment plan dated in June 2022. The treatment plan included a review date for July 11, 2022, August 11, 2022 and September 11, 2022. The record also revealed a treatment plan dated in September 2022 and October 2022. However, updated treatment plans dated in April 2022, May 2022, July 2022, and August 2022 were not available for review.

2. A review of R2’s medical record revealed a treatment plan dated in October 2022. The treatment plan included review dates for November 2022 and December 2022. However, an updated treatment plan dated in November 2022 was not available for review.

3. A review of R3’s medical record revealed a treatment plan dated in January 2022. The treatment plan included review dates for February 28, 2022, March 30, 2022, and April 30, 2022. The record also revealed a treatment plan dated in April 2022. The treatment plan included review dates for May 30, 2022, June 30, 2022, and July 30, 2022. The record also revealed a treatment plan dated in July 2022. The treatment plan included review dates for August 27, 2022, September 27, 2022, and October 27, 2022. The record also revealed a treatment plan dated in October 2022. However, an updated treatment plans dated in February 2022, March 2022, May 2022, June 2022, August 2022, and September 2022 was not available for review.

4. In an interview, E1 acknowledged R1’s, R2’s, and R3’s treatment plans were not reviewed and updated on an on-going basis according to the review date specified in R1’s, R2’s, and R3’s treatment plans. Date permanent correction will be complete: 2023-01-18

Rule: C. An administrator shall ensure that:

2. Each counseling session is documented in a resident’s medical record to include: a. The date of the counseling session; b. The amount of time spent in the counseling session; c. Whether the counseling was individual counseling, family counseling, or group counseling; d. The treatment goals addressed in the counseling session; and e. The signature of the personnel member who provided the counseling and the date signed.
Evidence: Based on record review and interview, the administrator failed to ensure each group counseling session was documented in a resident’s medical record to include the requirements in R9-10-716(C)(2), for three of three residents sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not in the medical records during the inspection, and the documentation was not provided within two hours after a Department request.

Findings:

1. A review of R1’s medical record revealed group counseling notes on the following dates: – December 19, 2022; -December 12, 2022; – November 28, 2022; and -October 31, 2022. However, the counseling notes did not include the requirements in R9-10-716(C)(2)(e).

2. A review of R1’s medical record revealed individual counseling notes on the following dates: -December 19, 2022; -December 11, 2022; -November 27, 2022; -November 7, 2022; and -October 31, 2022. However, the counseling notes did not include the requirements in R9-10-716(C)(2)(e).

3. A review of R1’s medical record revealed family counseling notes on the following dates: – December 20, 2022; -December 13, 2022; – November 29, 2022; -November 8, 2022; and – November 1, 2022. However, the counseling notes did not include the requirements in R9- 10-716(C)(2)(e).

4. A review of R1’s medical record revealed a group and individual counseling note on the following date: – October 24, 2022. However, the counseling notes did not include the requirements in R9- 10-716(C)(2)(b)(e).

5. A review of R2’s medical record revealed group counseling notes on the following dates: -December 19, 2022; – December 12, 2022; -November 28, 2022; – November 6, 2022; and -October 31, 2022. However, the counseling notes did not include the requirements in R9-10-716(C)(2)(e).

6. A review of R2’s medical record revealed individual counseling notes on the following dates: -December 18, 2022; -December 11, 2022; -November 27, 2022; -November 6, 2022; and -October 30, 2022. However, the counseling notes did not include the requirements in R9-10-716(C)(2)(e). 7. A review of R2’s medical record revealed a group counseling note on the following date: – October 24, 2022. However, the counseling note did not include the requirements in R9- 10-716(C)(2)(b)(e). 8. A review of R2’s medical record revealed a individual counseling note on the following date: -October 23, 2022. However, the counseling note did not include the requirements in R9-10-716(C)(2)(b)(e). 9. A review of R3’s medical record revealed group counseling notes on the following dates: – December 19, 2022; -December 12, 2022; – November 28, 2022; -November 7, 2022; and – October 31, 2022. However, the counseling notes did not include the requirements in R9- 10-716(C)(2)(e). 10. A review of R3’s medical record revealed individual counseling notes on the following dates: -December 18, 2022; – December 11, 2022; -November 27, 2022; – November 6, 2022; and -October 30, 2022. However, the counseling notes did not include the requirements in R9-10-716(C)(2)(e). 11. A review of R3’s medical record revealed a group counseling note on the following date: – October 24, 2022. However, the counseling note did not include the requirements in R9- 10-716(C)(2)(b)(e). 12. A review of R3’s medical record revealed a individual counseling note on the following date: – October 23, 2022. However, the counseling note did not include the requirements in R9- 10-716(C)(2)(b)(e). 13. In an interview, E1 acknowledged each counseling session was not documented in R1’s, R2’s, and R3’s medical records to include the requirements in R9-10- 716(C)(2)(b)(e). Date permanent correction will be complete 2023-01-18 Monitoring

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

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
Evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a behavioral health technician (BHT)completed training before providing assistance in the self-administration of medication, for one of two behavioral health technicians sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not in the personnel record during the inspection, and the documentation was not provided within two hours after a Department request. Findings include:

1. A review of the facility’s policies and procedures revealed a policy titled “Staff Training and Orientation” (dated November 15, 2022). The policy stated “Assistance in the self- administration of medication is provided only by: Agency staff members will be trained by nurse in assistance in the self administration of medication and documented according to R9- 10-718(C), although training to obtain skills and knowledge may be obtained from another agency, entity or staff member: The nurse will review the following with the staff.”

2. A review of E1’s personnel record revealed E1 was hired as a BHT. However, documentation of completed training in the assistance in the self-administration of medication was not available for review.

3. A review of R1’s medical record revealed a medication administration record (MAR) for December 2022. The MAR revealed E1 provided assistance in the self- administration of medication to R1.

4. A review of R2’s medical record revealed a medication administration record (MAR) for November 2022. The MAR revealed E1 provided assistance in the self-administration of medication to R2.

5. A review of R3’s medical record revealed a medication administration record (MAR) for December 2022. The MAR revealed E1 provided assistance in the self- administration of medication to R3.

6. In an interview, E1 acknowledged documentation of completed training in the assistance in the self- administration of medication for E1 was not available for review. Date permanent correction will be complete: 2023-01-18

Findings:

Compliance (Annual) on 12/27/2022

Findings:

3. A review of E5’s (hired in 2022) personnel record revealed documentation of compliance with A.R.S. \’a7 36-411(C)(1) was not available for review.

4. A review of E6’s (hired in 2022) personnel record revealed documentation of compliance with A.R.S. \’a7 36-411(C)(1) was not available for review.

Rule: 36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition A. Each health care institution shall develop and administer a training program for all staff regarding fall prevention and fall recovery. The training program shall include initial training and continued competency training in fall prevention and fall recovery. A health care institution may use information and training materials from the department’s Arizona falls prevention coalition in developing the training program.
Evidence: Based on documentation review, record review and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery to include initial training and continued competency training in fall prevention and fall recovery.

Findings:

Rule: B. An administrator:

Findings:

1. The Compliance Officer observed E2 on the premises and working alone upon arrival at 9:10 AM.

2. The Compliance Officer observed E1 arrive on the premises at approximately 9:15 AM.

3. In a interview, E2 reported E1 was the day shift personnel member and E1 would assist with the inspection, as E2 was the night shift personnel member.

Rule: C. An administrator shall ensure that:

3. A review of E2’s personnel record revealed documentation of CPR and first aid training from NationalCPRFoundation, issued on November 29, 2021 with an expiration date of November 29, 2023.

4. A review of E5’s personnel record revealed documentation of CPR and first aid training from NationalCPRFoundation, issued on September 19, 2022 with an expiration date of September 19, 2024.

5. A review of E7’s personnel record revealed documentation of CPR and first aid training from NationalCPRFoundation, issued on September 15, 2019 with an expiration date of September 15, 2021.

Findings:

Rule: C. An administrator shall ensure that:

Findings:

2. A review of E2’s personnel record revealed documentation of CPR and first aid training from NationalCPRFoundation, issued on November 29, 2021 with an expiration date of November 29, 2023.

3. A review of E5’s personnel record revealed documentation of CPR and first aid training from NationalCPRFoundation, issued on September 19, 2022 with an expiration date of September 19, 2024.

4. A review of E7’s personnel record revealed documentation of CPR and first aid training from NationalCPRFoundation, issued on September 15, 2019 with an expiration date of September 15, 2021.

Rule: An administrator shall ensure that:

Findings:

2. A review of the facility’s daily staffing schedule revealed E3 was the on-call BHP.

3. A review of R1’s medical record revealed a group counseling note signed by E3 on the following date: -July 28, 2022.

4. A review of R1’s medical record revealed a treatment plan signed by E3 (dated in September 2022 and October 2022).

5. A review of R3’s medical record revealed a treatment plan signed by E3 (dated in October 2022).

6. In an interview, E1 acknowledged documentation of current contracted services was not available for review. Date permanent correction will be complete: 2023-03-08

Rule: B. An administrator shall ensure that:

3. A review of R1’s (admitted in 2022) medical record revealed individual and group counseling notes to indicate E6 provided the counseling sessions.

4. A review of R2’s (admitted in 2022) medical record revealed individual and group counseling notes to indicate E6 provided the counseling sessions.

5. A review of R3’s (admitted in 2020) medical record revealed individual and group counseling notes to indicate E6 provided the counseling sessions.

Findings:

Rule: G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes:

3. A review of E6’s (hired in 2022) personnel record revealed documentation of completed orientation was not available for review.

Rule: A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that:

6. Is reviewed and updated on an on-going basis: a. According to the review date specified in the treatment plan,
Evidence: Based on record review and interview, the administrator failed to ensure a treatment plan for each resident was reviewed and updated on an on-going basis according to the review date specified in the treatment plan, for three of three residents sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not in the medical records during the inspection, and the documentation was not provided within two hours after a Department request.

Findings:

Rule: C. An administrator shall ensure that:

Findings:

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

3. A review of R1’s medical record revealed a medication administration record (MAR) for December 2022. The MAR revealed E1 provided assistance in the self- administration of medication to R1.

4. A review of R2’s medical record revealed a medication administration record (MAR) for November 2022. The MAR revealed E1 provided assistance in the self-administration of medication to R2.

5. A review of R3’s medical record revealed a medication administration record (MAR) for December 2022. The MAR revealed E1 provided assistance in the self- administration of medication to R3.

Findings:

Complaint on 10/31/2023

Rule: K. An administrator shall:

6. Establish and document the criteria for determining when a resident’s absence is unauthorized, including criteria for a resident who: c. Is under the age of 18;
Evidence: Based on documentation review and interview, the administrator failed to establish and document the criteria for determining when a resident’s absence was unauthorized, including criteria for a resident who is under the age of 18. The deficient practice posed a risk as criteria reinforce and clarifies the health care institution’s standards.

Findings:

1. A review of the facility’s policies and procedures revealed a policy and procedure titled “Unauthorized Absences Quality Management procedures” (dated November 15, 2022). The policy stated “Agency will conduct and complete the following. Document on the Internal Audit Checklist unauthorized absences and actions taken. Agency staff members will document the unauthorized absences in incident report and during clinical supervision agency team members will evaluate how to prevent incidents from continuing to occur. Agency will track number of unauthorized absences on yearly log. During clinical supervision agency team members will discuss client that was AWOL from the agency and discuss services that could have prevented client from leaving. Complete Incident Report / AWOL / Unauthorized Absences; Incident details.” However, the policy did not include the criteria for determining when a resident’s absence was unauthorized, including criteria for a resident who is under the age of 18.

2. In a joint interview, E1 and E2 acknowledged the criteria for determining when a resident’s absence was unauthorized, including criteria for a resident who is under the age of 18, was not established and documented. Date permanent correction will be complete:

Rule: K. An administrator shall: 9. Evaluate and take action related to unauthorized absences under the quality management program in R9-10-704.
Evidence: Based on documentation review and interview, the administrator failed to evaluate and take action related to unauthorized absences under the quality management program in R9-10- 704. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided, and posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include:

1. A review of facility documentation revealed a document titled “[R1] Investigation” (undated). The document stated “[R1] went AWOL around midnight of October 15, 2023.”

2. A review of the facility’s policies and procedures revealed a policy and procedure titled “Unauthorized Absences Quality Management procedures” (dated November 15, 2022). The policy stated “Agency will conduct and complete the following. Document on the Internal Audit Checklist unauthorized absences and actions taken. Agency staff members will document the unauthorized absences in incident report and during clinical supervision agency team members will evaluate how to prevent incidents from continuing to occur.During clinical supervision agency team members will discuss client that was AWOL from the agency and discuss services that could have prevented client from leaving.”

3. A review of facility documentation revealed a document titled “Internal Audit Checklist” (dated March 8, 2023). However, documentation of R1’s unauthorized absences and documentation of actions taken documented on an Internal Audit Checklist was not available for review.

4. A review of electronic documentation, provided by E1, revealed an email with a subject of “To Do list” (dated October 12, 2023). However, documentation of R1’s unauthorized absence and documentation of actions taken documented on an Internal Audit Checklist was not available for review.

5. A review of facility documentation revealed a document titled “Clinical Oversight Form for BHT’s” (dated October 30, 2023). The document stated “.Supervision Topic: Fall Prevention and CPI.We looked at Fall Prevention today. We also worked with CPI. The workers at the organization now have a good idea what to look for in fall prevention and what to do if a person falls.We also talked about CPI with the clients we see.” However, documentation to indicate R1’s unauthorized absence and actions taken was not available for review.

6. In a joint interview, E1 and E2 acknowledged the facility did not evaluate and take action related to R1’s unauthorized absence. Date permanent correction will be complete:

Findings:

Rule: G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes:

3. Documentation of: e. The individual’s compliance with requirements in A.R.S. §§ 36-411, 36-411.01, and 36-425.03, as applicable;
Evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of compliance with the requirements in A.R.S. \’a7 36-425.03(E), for one of three personnel members sampled. The deficient practice posed a risk if E1 was a danger to a vulnerable population. Findings include: A.R.S. \’a7 36-425.03(E) states “Children’s behavioral health program personnel shall certify on forms that are provided by the department and notarized that they are not awaiting trial on or have never been convicted of or admitted in open court or pursuant to a plea agreement to committing any of the offenses listed in section 41- 1758.03, subsection B or C in this state or similar offenses in another state or jurisdiction.”

1. A review of Department documentation revealed BH3031 was licensed as a children’s behavioral health residential facility, effective July 7, 2008.

2. A review of E1’s personnel record revealed documentation of compliance with A.R.S. \’a7 36-425.03(E) was not available for review.

3. In an interview, E1 reported the documentation was in another folder. However, documentation of compliance with A.R.S. \’a7 36-425.03(E) was not provided for review.

4. In a joint interview, E1 and E2 acknowledged E1’s personnel record did not include documentation of compliance with A.R.S. \’a7 36-425.03(E). Date permanent correction will be complete:

Findings:

Complaint on 1/25/2024

Rule: C. An administrator shall ensure that:

Findings:

1. The Compliance Officer requested to review E4’s complete personnel record, per R9-10- 706.G.1-3 at 12:15 PM.

2. A review of E4’s personnel record revealed documentation of CPR training, dated December 21, 2023 from American Red Cross. However, the CPR training card stated “Adult, Child and Baby First Aid/CPR/AED Online (Eligible for Skills Session within 90 days).”

3. In an interview, E1 reported E4 had a different CPR training which included a hands on demonstration. However, a CPR training to include a demonstration was not provided for review.

4. A review of electronic documentation, provided by E1 at 3:17 PM revealed a CPR training to include a demonstration for E4.

5. In an interview, E1 acknowledged documentation required by Article 7 was not provided to the Department within two hours after a Department request. Date permanent correction will be complete: 2024-09-20

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

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

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

6. Maintain a copy of the documented information required in subsection (I)(5) and any other information obtained during the investigation for at least 12 months after the date the investigation was initiated.
Evidence: Based on documentation review and interview, the administrator failed to ensure if an administrator had a reasonable basis, according to A.R.S. \’a7 13-3620, to believe abuse occurred on the premises or while a resident was receiving services from a behavioral health residential facility’s employee or personnel member, the administrator initiated an investigation of the suspected abuse. The deficient practice posed a risk as the licensee was unable to assess if there was an immediate health and safety concern for the other residents residing in the behavioral health residential facility. Findings include: A.R.S. \’a7 13-3620(A) states any person who reasonably believes that a minor is or has been the victim of physical injury, abuse, child abuse, a reportable offense or neglect that appears to have been inflicted on the minor by other than accidental means or that is not explained by the available medical history as being accidental in nature or who reasonably believes there has been a denial or deprivation of necessary medical treatment or surgical care or nourishment with the intent to cause or allow the death of an infant who is protected under section 36-2281 shall immediately report or cause reports to be made of this information to a peace officer, to the department of child safety or to a tribal law enforcement or social services agency for any Indian minor who resides on an Indian reservation, except if the report concerns a person who does not have care, custody or control of the minor, the report shall be made to a peace officer only.

1. A review of the facility’s policies and procedures revealed a policy titled “Reporting Incidents” (dated November 15, 2022). The policy stated “.A required report is a situation that requires a staff member to create an incident report. Behavioral Health Residential Facilities Licensing (BRFL) must [sic] be notified of the incident dependent on the nature of the incident. BRFL must [sic] be notified in writing by submitting an incident report.If suspected Abuse, neglect, or exploitation occurred while a resident is receiving services at the facility from an employee, the administrator will.if applicable, take immediate action to stop the suspected abuse.report the suspected abuse.document the suspected abuse.any action taken according to R9-10-703(H)(1) [sic] .Initiate an investigation of the suspected abuse.and document the following information within five working days after the report has been made.The dates, times, and description of the suspected abuse.A description of any injury to the resident related to the suspected abuse.and any change to the resident’s physical, cognitive, functional, or emotional condition.the names of witnesses.The actions taken by the administrator to prevent the suspected abuse, neglect, or exploitation from occurring in the future.Program director and agency administrator will review all incident reports within 24 hours of the incident.”

2. A review of Department documentation revealed a complaint submitted to the Department on November 27, 2023. The complaint stated “.On 11/23/23, [R2] stated someone at the group home beat [R2] up and that it was an adult.[R2] stated that [R2] has scars on [R2’s] face now. It is unknown if the scars are bruises or cuts. [R2] was told to tell another adult and [R2] stated that [R2] did, but that no one cares. It was stated the incident occurred on 11/22/2023.”

3. A review of electronic documentation, provided by E2, revealed a forwarded email, dated January 25, 2024. The email was sent by E5 to E1. The email stated “On the above day and time, staff [E5] had just arrived on shift.Client [R2] was in [R2’s] room laying on [R2’s] bed. Staff sat on [R2’s] bed and asked if [R2] was okay. [R2] stated that [R2] missed [R2’s] mom and that [R2] was mad that [R2’s] visits now were shorter on Saturday, now that [R2’s] siblings didn’t come to visits anymore and that made [R2] angry because [R2] felt [R2’s] mom did not want to spend time with just [R2] without [R2’s] siblings present. Staff processed with [R2] about understanding that [R2’s] parent was trying to do the right thing and was still sad about everything that had happened. [R2] stated that [R2] didn’t care about what she was going through and that [R2] was sick and tired of her excuses. Furthermore, [R2] was tired of living at this group home and was tired of staff abusing [R2]. [R2] stated that [R2] received the scratch on [R2’s] face from Staff the day before but when staff reminded client [R2] that this staff spoke with client the night before about what had occurred with the AWOL and how [R2] had told staff [R2] was running in trees when staff was looking for client. Client [R2] became upset and stated that [R2] never said that and that this staff was lying. Staff gave client [R2’s] space and continued to get Thanksgiving dinner ready to serve. Staff [E5] and [E2] came back to check on client [R2] who was on the phone with [R2’s] uncle.stating that the staff at the group home daily abuse [R2], not feed him and caused a scratch on [R2’s] cheek.” 9. In an interview, E1 reported the Department of Child Safety (DCS) was called on November 24, 2023. However, documentation of the requirements in R9-10-703.I.1-6 was not available for review. 10. In an interview, E1 acknowledged the findings. Date permanent correction will be complete: 2024-02-14

Findings:

1. On or before the date the individual begins providing services at or on behalf of the behavioral health residential facility, and

2. As specified in R9-10-113. Evidence Based on record review and interview, the administrator failed to ensure a personnel member provided evidence of freedom from infectious tuberculosis (TB), as specified in Arizona Administrative Code (A.A.C.) R9-10- 113(B)(2), for one of three personnel members sampled. The deficient practice posed a TB exposure risk to residents.

Findings: A.A.C. R9-10-113(B)(2) states: “B. A health care institution’s chief administrative officer shall:

1. A review of E4’s personnel records revealed documented evidence of freedom from infectious TB, dated in December 2023. However, a two-step TB test was not available for review.

2. In an interview, E1 acknowledged documented evidence of freedom from infectious TB for E4 was not available for review. Date permanent correction will be complete: 2024-02-14

Rule: G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes:

3. Documentation of: h. Cardiopulmonary resuscitation training, if required for the individual according to R9-10- 703(C)(1)(e);
Evidence: Based on record review and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of cardiopulmonary resuscitation (CPR) training to include a demonstration, for one of three personnel members sampled. The deficient practice posed a risk if E4 was unable to perform CPR.

Findings:

1. A review of E4’s personnel record revealed documentation of CPR training, dated December 21, 2023 from American Red Cross. However, the CPR training card stated “Adult, Child and Baby First Aid/CPR/AED Online (Eligible for Skills Session within 90 days).”

2. In an interview, E1 reported E4 had a different CPR training which included a hands on demonstration. However, a CPR training to include a demonstration was not available for review.

3. A review of electronic documentation, provided by E1 at 3:17 PM revealed a CPR training to include a demonstration for E4.

4. In an interview, E1 acknowledged E4’s personnel record did not include E4’s current CPR training to include a demonstration. This Rule was cited on August 3, 2023. A letter sent to the facility, dated August 14, 2023, stated “.the Department requires that you make immediate corrections of violations that present a threat to the health or safety of a client, resident, patient or agency personnel. Additionally, the Department urges correction of all deficiencies at the earliest possible date.” Date permanent correction will be complete: 2024-02-14

Rule: D. An administrator shall ensure that there is a documented discharge order by a medical practitioner or behavioral health professional before a resident is discharged unless the resident leaves the behavioral health residential facility against a medical practitioner’s or behavioral health professional’s advice.
Evidence: Based on record review and interview, the administrator failed to ensure there was a documented discharge order by a medical practitioner or behavioral health professional before a resident was discharged, for one of one discharged resident who did not leave the behavioral health residential facility against a medical practitioner’s or behavioral health professional’s (BHP) advice.

Findings:

1. A review of R1’s medical record revealed a discharge summary (dated in December 2023). The document was signed by the BHP. However, a documented discharge order by a medical practitioner or behavioral professional before R1 was discharged was not available for review.

2. In an interview, E1 acknowledged R1 did not have a documented discharge order by a medical practitioner or behavioral health professional. Date permanent correction will be complete: 2024-02-14

Complaint on 1/21/2025

Rule: A. An administrator shall ensure that:

6. Except as provided in subsection (E)(1)(a), a medical practitioner performs a medical history and physical examination or a registered nurse performs a nursing assessment on a resident within 30 calendar days before admission or within 72 hours after admission and documents the medical history and physical examination or nursing assessment in the resident’s medical record within 72 hours after admission;
Evidence: Based on record review and interview, the administrator failed to ensure a medical practitioner performed a medical history and physical examination or a registered nurse performed a nursing assessment on a resident within 30 calendar days before admission or within 72 hours after admission, for one of two residents sampled. The deficient practice posed a risk as this information was required for the development and implementation of a treatment plan, per R9-10-708.A.1. Findings include:

1. A review of R2’s (admitted in March 2024) medical record revealed documentation to indicate a medical history and physical examination or nursing assessment was completed within 30 calendar days before admission or within 72 hours after admission was not available for review.

2. In an exit interview, E1 acknowledged a medical history and physical exam or a nursing assessment for R2 was not performed. Date permanent correction will be complete:

Findings:

Rule: A. An administrator shall ensure that: 9. Except as provided in subsection (A)(10), a behavioral health assessment for a resident is completed before treatment for the resident is initiated;
Evidence: Based on record review and interview, the administrator failed to ensure a behavioral health assessment was completed before treatment for the resident was initiated, for one of two residents sampled. The deficient practice posed a risk as an analysis of the resident’s needs for behavioral health services to determine which services a health care institution would provide was not completed.

Findings:

1. A review of R1’s (admitted in November 2024) medical record revealed a behavioral health assessment dated ten calendar days after R1’s date of admission.

2. A review of R1’s medical record revealed group counseling sessions, prior to the completion of R1’s behavioral health assessment, on the following dates: -November 12, 2024; – November 13, 2024; -November 19, 2024; and -November 20, 2024.

3. In an exit interview, E1 acknowledged R1’s behavioral health assessment was not completed before treatment was initiated. Date permanent correction will be complete:

Rule: A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that:

Findings:

1. A review of R1’s (admitted in November 2024) medical record revealed a treatment plan dated ten calendar days after R1’s date of admission.

2. A review of R1’s medical record revealed group counseling sessions, prior to the completion of R1’s treatment plan, on the following dates: – November 12, 2024; -November 13, 2024; – November 19, 2024; and -November 20, 2024.

3. In an exit interview, E1 acknowledged R1’s behavioral health assessment was not completed before receiving behavioral health services. Date permanent correction will be complete:

Rule: A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that:

4. Includes: c. The signature of the resident or the resident’s representative, and date signed, or documentation of the refusal to sign;
Evidence: Based on record review and interview, the administrator failed to ensure a treatment plan was developed for each resident to include the signature of the resident’s representative, and the date signed, or documentation of the refusal to sign, for one of two residents sampled. The deficient practice posed a risk if the treatment plan was not developed to articulate decisions and agreements. Findings include:

1. A review of R1’s medical record revealed a treatment plan (dated in November 2024). However, the treatment plan did not include the signature of the resident’s representative, and the date signed, or documentation of the refusal to sign.

2. In an exit interview, E1 acknowledged R1’s treatment plan did not include the signature of the resident’s representative, and date signed, or documentation of the refusal to sign. Date permanent correction will be complete:

Findings:

Rule: A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that:

6. Is reviewed and updated on an on-going basis: a. According to the review date specified in the treatment plan,
Evidence: Based on record review and interview, the administrator failed to ensure a developed treatment plan was reviewed and updated on an on-going basis according to the review date specified in the treatment plan, for one of two residents sampled. The deficient practice posed a risk as an analysis of the resident’s needs for behavioral health services was not reviewed and updated.

Findings:

1. A review of R2’s medical record revealed an updated treatment plan dated in September 2024. The treatment plan contained a review date in December 2024. However, a reviewed and updated treatment plan was not available for review.

2. In an exit interview, E1 acknowledged R1’s treatment plan had not been reviewed and updated according to the review date specified in the treatment plan. Date permanent correction will be complete:

Rule: C. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that food is obtained, prepared, served, and stored as follows:

1. Food is free from spoilage, filth, or other contamination and is safe for human consumption;
Evidence: Based on observation and interview, the administrator failed to ensure food was free from spoilage, filth, or other contamination and was safe for human consumption. The deficient practice posed a food-borne illness risk to residents.

Findings:

1. The Compliance Officer observed “Classic Garden” lettuce in the kitchen refrigerator with an expiration date of January 13, 2025. The lettuce appeared to be spoiled.

2. In an exit interview, E1 acknowledged the food in the refrigerator was not free from spoilage. Date permanent correction will be complete:

Rule: A. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that:

1. The premises and equipment are: a. Maintained in a condition that allows the premises and equipment to be used for the original purpose of the premises and equipment; b. Cleaned and, if applicable, disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection; and c. Free from a condition or situation that may cause a resident or other individual to suffer physical injury;
Evidence: Based on observation and interview, the administrator failed to ensure the premises was maintained in a condition that allowed the premises to be used for the original purpose, cleaned and, and control illness or infection, and free from a condition or situation that may cause a resident or other individual to suffer physical injury.

Findings:

1. The Compliance Officer observed in the kitchen, accessible to residents, the following: a broken wood panel located on the island.

2. The Compliance Officer observed in the privacy room, accessible to residents, the following: a broken window.

3. The Compliance Officer observed in a shared resident’s bedroom the following: a broken window covered by a large wood panel, and what appeared to be food debris splattered on the wall.

4. The Compliance Officer observed in a shared resident’s bedroom the following: holes in the wall, and missing drawers in a nightstand.

5. The Compliance Officer observed in a shared bathroom located in a shared resident’s bedroom the following: broken tiles exposing sharp edges, exposed outlets missing the face cover, a missing privacy curtain, and what appeared to be vomit located near the toilet, and brownish discoloring on the floor located near the toilet.

6. The Compliance Officer observed on the exterior of the premises from the backyard, accessible to residents the following: holes in the wall, holes in a pillar structure exposing foundational wires. 7. In an interview, E1 reported all the issues were in the process of being fixed and/or looked at for repair. 8. The Compliance Officer observed two individuals arrive on-site to replace the window in the privacy room. 9. In an exit interview, E1 acknowledged the premises was not in a condition that allowed the premises to be used for the original purpose, cleaned and, and free from a condition or situation that may cause a resident or other individual to suffer physical injury. Date permanent correction will be complete:

ANGEL SAFE HAVEN LLC
2571 North 149th Avenue, Goodyear, AZ 85395

Complaint on 9/26/2024

Rule: C. An administrator shall ensure that:

1. Policies and procedures are established, documented, and implemented to protect the health and safety of a resident that: e. Cover cardiopulmonary resuscitation training including: i. The method and content of cardiopulmonary resuscitation training, which includes a demonstration of the individual’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 individual has received cardiopulmonary resuscitation training;
Evidence: Based on documentation review, record review, and interview, the administrator failed to implement policies and procedures to protect the health and safety of a resident to cover cardiopulmonary resuscitation (CPR) training to include a demonstration of the individual’s ability to perform cardiopulmonary resuscitation. The deficient practice posed a risk if E5 was unable to meet a resident’s needs during an accident or emergency, and the facility’s standards were not followed. Findings include:

1. A review of the facility’s policies and procedures revealed a policy titled “Staffing of Residential Facilities- Employees ” (dated August 1, 2022). The policy stated “. J. The agency shall provide staff members who have current documentation of successful completion of First Aid and CPR training for adolescents that includes demonstration of the staff member’s ability to perform CPR at the facility or on outings.”

2. A review of the facility’s policies and procedures revealed a policy titled “Cardiopulmonary Resuscitation CPR” (dated August 1, 2022). The policy stated “. b. No online training will be acceptable. All CPR training must be completed in person.”

3. A review of facility documentation revealed a daily staffing schedule for September 2024. The schedule revealed E5 was scheduled to work alone on the following dates and the following times: -September 16, 2024: 2:00PM to 11:00PM; -September 20, 2024: 2:00PM to 11:00PM; -September 21, 2024: 9:00AM to 9:00PM; -September 27, 2024: 2:00PM to 10:00PM; and -September 28, 2024: 9:00AM to 9:00PM.

4. A review of E5’s (hired in 2024) personnel record revealed E5 was hired as a BHT. E5’s personnel record revealed documentation of CPR training from “NationalCPRFoundation” issued January 12, 2024. The document stated “Valid for 2 years.”

5. A review of the “NationalCPRFoundation” website revealed courses were conducted online. The “NationalCPRFoundation” website stated the following: -“Help Save Lives Today with Your Online CPR Certification Training!” – “All courses can be completed online in just a few hours or less. Once you have completed an examination via our quick and easy online system, you will receive a PDF copy of your certificate immediately via email as well as your card within 2-5 business days;” and – “Online training is a legal and acceptable form of training, however, NCPRF\’ae does not offer in-person training. Your employer or licensing board may require in-person training for “special industries”. You should consult with your employer if you have questions about whether our certification will be accepted. Therefore, we cannot guarantee that our certification will be accepted in every situation.”

6. In an interview, E1 reported E1 did not observe E5’s demonstration of hands- on [CPR] training. 7. In an interview, the findings were reviewed with E1 and no additional comments or statements were provided regarding the findings. Date permanent correction will be complete:

Findings:

Rule: C. An administrator shall ensure that:

Findings:

1. The Compliance Officer requested, at 9:18AM and at 11:07AM, E4’s documentation of baseline screening consisting of the individual’s freedom from infectious TB, per R9-10-113(A) (2)(a)(iii) of two-step testing. However, documentation of E4’s two-step testing was not provided for review within two hours after a Department request.

2. The Compliance Officer requested, at 9:18AM and at 11:10AM, E5’s documentation of baseline screening consisting of the individual’s freedom from infectious TB, per R9-10-113(A)(2)(a)(iii) of two-step testing. However, documentation of E5’s two-step testing was not provided for review within two hours after a Department request.

3. In an interview, E1 reported E4 and E5 had documentation of baseline screening consisting of the individual’s freedom from infectious TB, per R9-10-113(A)(2)(a)(iii) of two-step testing; however, this documentation was on E1’s desk at E1’s personal residence.

4. In an interview, the findings were reviewed with E1 and no additional comments or statements were provided regarding the findings. This Rule was cited during the compliance inspection conducted on June 5, 2024. A letter, dated June 12, 2024, stated “Enclosed is a copy of the Statement of Deficiencies (SOD), which describes the violations the Department found at the facility. Because the case has been referred to the Enforcement Team, the Department is not requesting a WRITTEN Plan of Correction (POC) at this time. However, the Department requires that you make immediate corrections of violations that present a threat to the health or safety of a client, resident, patient or agency personnel and still requires that you make corrections to all violations noted in the SOD.” Date permanent correction will be complete:

Rule: B. An administrator shall ensure that:

3. Sufficient personnel members are present on a behavioral health residential facility’s premises with the qualifications, experience, skills, and knowledge necessary to: c. Ensure the health and safety of a resident.
Evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel member, employee, volunteer, or student to include documentation of cardiopulmonary resuscitation (CPR) training, if required for the individual according to R9-10-703(C)(1)(e); and first aid training, if required for the individual according to this Article or policies and procedures. The deficient practice posed a risk if E2 and E5 were unable to ensure the health and safety of a resident.

Findings:

3. A review of facility documentation revealed a daily staffing schedule for September 2024. The schedule revealed E2 was scheduled to work alone on the following dates and the following times: – September 2, 2024: 6:00PM to 11:00PM; – September 3, 2024: 8:00AM to 2:00PM; – September 4, 2024: 12:00PM to 8:00PM; – September 5, 2024: 6:00PM to 8:00AM; – September 8, 2024: 5:00PM to 8:00AM; – September 9-10, 2024: :700PM to 11:00PM; – September 11, 2024: 8:00AM to 11:00PM; – September 14-15, 2024: 9:00AM to 9:00PM; – September 22, 2024: 9:00AM to 9:00AM; – September 23, 2024: 7:00PM to 11:00PM; – September 25-26, 2024: 7:00PM to 11:00PM; and -September 29, 2024: 9:00AM to 11:00PM.

4. A review of facility documentation revealed a daily staffing schedule for September 2024. The schedule revealed E5 was scheduled to work alone on the following dates and the following times: -September 16, 2024: 2:00PM to 11:00PM; -September 20, 2024: 2:00PM to 11:00PM; -September 21, 2024: 9:00AM to 9:00PM; -September 27, 2024: 2:00PM to 10:00PM; and -September 28, 2024: 9:00AM to 9:00PM.

5. A review of E2’s (hired in 2018) personnel record revealed E2 was hired as a behavioral health technician (BHT). The personnel record revealed documentation of CPR training (issued November 8, 2022, expires November 8, 2024). However, documentation of first aid training was not available for review.

6. In an interview, E1 reported E2 completed first aid training, however, this documentation was not available for review. 7. A review of E5’s (hired in 2024) personnel record revealed E5 was hired as a BHT. E5’s personnel record revealed documentation of CPR training from “NationalCPRFoundation” issued January 12, 2024. The document stated “Valid for 2 years.” 8. A review of the “NationalCPRFoundation” website revealed courses were conducted online. The “NationalCPRFoundation” website stated the following: -“Help Save Lives Today with Your Online CPR Certification Training!” – “All courses can be completed online in just a few hours or less. Once you have completed an examination via our quick and easy online system, you will receive a PDF copy of your certificate immediately via email as well as your card within 2-5 business days;” and – “Online training is a legal and acceptable form of training, however, NCPRF\’ae does not offer in-person training. Your employer or licensing board may require in-person training for “special industries”. You should consult with your employer if you have questions about whether our certification will be accepted. Therefore, we cannot guarantee that our certification will be accepted in every situation.” 9. In an interview, E1 reported E1 did not observe E5’s demonstration of hands- on [CPR] training. 10. In an interview, the findings were reviewed with E1 and no additional comments or statements were provided regarding the findings. This Rule was cited during the compliance inspection conducted on June 5, 2024. A letter, dated June 12, 2024, stated “Enclosed is a copy of the Statement of Deficiencies (SOD), which describes the violations the Department found at the facility. Because the case has been referred to the Enforcement Team, the Department is not requesting a WRITTEN Plan of Correction (POC) at this time. However, the Department requires that you make immediate corrections of violations that present a threat to the health or safety of a client, resident, patient or agency personnel and still requires that you make corrections to all violations noted in the SOD.” Date permanent correction will be complete:

Rule: G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes:

3. Documentation of: e. The individual’s compliance with requirements in A.R.S. §§ 36-411, 36-411.01, and 36-425.03, as applicable;
Evidence: Based on record review and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of compliance with the requirements in Arizona Revised Statutes (A.R.S.) \’a7\’a7 36-425.03(E) (G), for one of five personnel records sampled. The deficient practice posed a risk if E5 was a danger to a vulnerable population. Findings include: A.R.S. \’a7\’a7 36-425.03(E) states “Children’s behavioral health program personnel shall certify on forms that are provided by the department and notarized that they are not awaiting trial on or have never been convicted of or admitted in open court or pursuant to a plea agreement to committing any of the offenses listed in section 41- 1758.03, subsection B or C in this state or similar offenses in another state or jurisdiction.” A.R.S. \’a7\’a7 36-425.03(G) states “Employers of children’s behavioral health program personnel shall make documented, good faith efforts to contact previous employers of children’s behavioral health program personnel to obtain information or recommendations that may be relevant to an individual’s fitness for employment in a children’s behavioral health program.”

1. A review of E5’s (hired in 2024) personnel record revealed E5 was hired as a behavioral health technician. E5’s personnel record revealed a valid fingerprint clearance card. The personnel record revealed documentation of A.R.S. \’a7\’a7 36-425.03(E) (dated September 12, 2024). However, the document stated ” . True False

1. I am not awaiting trial on or have never been convicted of or admitted in open court or pursuant to a plea agreement committing any of the offenses listed in A.R.S. \’a7\’a7 41- 1758.03(B), in this state or similar offenses in another state of jurisdiction” with the “False” checked.

2. In an interview, E1 reported E5’s form may have been filled out incorrectly. E1 reported E5 was not awaiting trial and has never been convicted of or admitted in open court or pursuant to a plea agreement committing any of the offenses listed in A.R.S. \’a7\’a7 41-1758.03(B), in this state or similar offenses in another state of jurisdiction.

3. A review of E5’s personnel record revealed documentation of compliance with the requirements in A.R.S. \’a7\’a7 36-425.03(G) was not available for review.

4. In an interview, E1 reported E1 contacted E5’s previous employers, however, this information was not documented.

5. In an interview, E1 acknowledged E5’s personnel record was not maintained to include documentation of compliance with the requirements in A.R.S. \’a7 36-425.03(E)(G). This Rule was cited during the compliance inspection conducted on June 5, 2024. A letter, dated June 12, 2024, stated “Enclosed is a copy of the Statement of Deficiencies (SOD), which describes the violations the Department found at the facility. Because the case has been referred to the Enforcement Team, the Department is not requesting a WRITTEN Plan of Correction (POC) at this time. However, the Department requires that you make immediate corrections of violations that present a threat to the health or safety of a client, resident, patient or agency personnel and still requires that you make corrections to all violations noted in the SOD.” Date permanent correction will be complete:

Findings:

Rule: G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes:

3. Documentation of: h. Cardiopulmonary resuscitation training, if required for the individual according to R9-10- 703(C)(1)(e); i. First aid training, if required for the individual according to this Article or policies and procedures; and
Evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel member, employee, volunteer, or student to include documentation of cardiopulmonary resuscitation (CPR) training, if required for the individual according to R9-10-703(C)(1)(e); and first aid training, if required for the individual according to this Article or policies and procedures. The deficient practice posed a risk if E2 and E5 were unable to meet a resident’s needs during an accident or emergency.

Findings:

3. A review of facility documentation revealed a daily staffing schedule for September 2024. The schedule revealed E2 was scheduled to work alone on the following dates and the following times: -September 2, 2024: 6:00PM to 11:00PM; -September 3, 2024: 8:00AM to 2:00PM; -September 4, 2024: 12:00PM to 8:00PM; -September 5, 2024: 6:00PM to 8:00AM; -September 8, 2024: 5:00PM to 8:00AM; -September 9-10, 2024: :700PM to 11:00PM; -September 11, 2024: 8:00AM to 11:00PM; -September 14-15, 2024: 9:00AM to 9:00PM; -September 22, 2024: 9:00AM to 9:00AM; -September 23, 2024: 7:00PM to 11:00PM; -September 25-26, 2024: 7:00PM to 11:00PM; and -September 29, 2024: 9:00AM to 11:00PM.

4. A review of facility documentation revealed a daily staffing schedule for September 2024. The schedule revealed E5 was scheduled to work alone on the following dates and the following times: – September 16, 2024: 2:00PM to 11:00PM; – September 20, 2024: 2:00PM to 11:00PM; – September 21, 2024: 9:00AM to 9:00PM; – September 27, 2024: 2:00PM to 10:00PM; and -September 28, 2024: 9:00AM to 9:00PM.

6. In an interview, E1 reported E2 completed first aid training. E1 reported E2’s aforementioned documentation of CPR training was the only documentation provided by the training agency. 7. A review of E5’s (hired in 2024) personnel record revealed E5 was hired as a BHT. E5’s personnel record revealed documentation of CPR training from “NationalCPRFoundation” issued January 12, 2024. The document stated “Valid for 2 years.” 8. A review of the “NationalCPRFoundation” website revealed courses were conducted online. The “NationalCPRFoundation” website stated the following: -“Help Save Lives Today with Your Online CPR Certification Training!” – “All courses can be completed online in just a few hours or less. Once you have completed an examination via our quick and easy online system, you will receive a PDF copy of your certificate immediately via email as well as your card within 2-5 business days;” and – “Online training is a legal and acceptable form of training, however, NCPRF\’ae does not offer in-person training. Your employer or licensing board may require in-person training for “special industries”. You should consult with your employer if you have questions about whether our certification will be accepted. Therefore, we cannot guarantee that our certification will be accepted in every situation.” 9. In an interview, E1 reported E1 did not observe E5’s demonstration of hands- on [CPR] training. 10. In an interview, E1 acknowledged a personnel record was not maintained to include documentation of CPR training according to R9-10-703(C)(1)(e) for E5; and and first aid training for E2. This Rule was cited during the compliance inspection conducted on June 5, 2024. A letter, dated June 12, 2024, stated “Enclosed is a copy of the Statement of Deficiencies (SOD), which describes the violations the Department found at the facility. Because the case has been referred to the Enforcement Team, the Department is not requesting a WRITTEN Plan of Correction (POC) at this time. However, the Department requires that you make immediate corrections of violations that present a threat to the health or safety of a client, resident, patient or agency personnel and still requires that you make corrections to all violations noted in the SOD.” Date permanent correction will be complete:

Rule: G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes:

3. Documentation of: j.
Evidence: of freedom from infectious tuberculosis, if required for the individual according to subsection (F). Evidence Based on documentation review, record review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of evidence of freedom from infectious tuberculosis (TB), if required for the individual according to subsection (F); for two of five personnel members sampled. The deficient practice posed a potential TB exposure risk to residents.

Findings: R9-10-706(F) An administrator shall ensure that a personnel member, or an employee, a volunteer, or a student who has or is expected to have more than eight hours of direct interaction per week with residents, provides evidence of freedom from infectious tuberculosis:

1. On or before the date the individual begins providing services at or on behalf of the behavioral health residential facility, and

2. As specified in R9-10-113. R9- 10-113(A)(2) If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution’s chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that:

1. A review of the CDC website revealed a web page titled ” Baseline Tuberculosis Screening and Testing for Health Care Personnel ” stated ” If the Mantoux tuberculin skin test (TST) is used for baseline testing of health care personnel, use two-step testing.”

2. A review of E4’s (hired in 2024) personnel record revealed E4 was hired as a behavioral health technician (BHT). E4’s personnel record revealed documentation of the individual’s freedom from infectious TB (dated September 11, 2024). However, documentation of baseline screening consisting of the individual’s freedom from infectious TB, per R9-10-113(A) (2)(a)(iii) of two-step testing, was not available for review.

3. A review of E5’s (hired in 2024) personnel record revealed E4 was hired as a behavioral health technician (BHT). E4’s personnel record revealed documentation of the individual’s freedom from infectious TB (dated September 11, 2024). However, documentation of baseline screening consisting of the individual’s freedom from infectious TB, per R9-10-113(A)(2)(a)(iii) of two-step testing, was not available for review.

4. In an interview, E1 reported E4 and E5 had documentation of baseline screening consisting of the individual’s freedom from infectious TB, per R9-10-113(A)(2)(a)(iii) of two-step testing; however, this documentation was on E1’s desk at E1’s personal residence.

5. In an interview, E1 acknowledged E4’s and E5’s documentation of freedom from infectious TB as specified in R9-10-113 was not available for review. Date permanent correction will be complete:

Rule: C. An administrator shall ensure that a resident’s medical record contains: 9. Orders;
Evidence: Based on record review, observation, and interview, the administrator failed to ensure a resident’s medical record contained orders, for one of three current residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper assistance in the self-administration of medication.

Findings:

1. A review of R1’s (admitted in 2024) medical record revealed a treatment plan (dated in 2024). The treatment plan revealed R1 received assistance in the self-administration of medication.

2. A review of R1’s medical record revealed a medication administration record (MAR) for September 2024. The MAR documented R1 received assistance in the self- administration of medication of “Hydroxyzine 25mg” on September 1-25, 2024. However, a signed medication order for the aforementioned medication was not available for review.

3. A review of R1’s medical record revealed a document titled “Current Medication List” (date unavailable). The document stated ” . Hydroxyzine TABLET – hydrochloride 25mg Take 1 tablet by mouth at bedtime .” and “Printed 08/13/2024 . Page 1 of

1.” However, the document was not signed by a medical practitioner.

4. The Compliance Officer observed medication bottle labeled for R1. The label stated “Hydroxyzine HCl 25 mg tablet . Take 1 tablet by mouth at bedtime for insomnia.” However, a signed medication order for Hydroxyzine HCl 25 mg tablet at bedtime was not available for review.

5. In an interview, E1 reported a signed medication order for R1’s Hydroxyzine was not available for review.

6. In an interview, E1 acknowledged R1’s medical record did not contain a signed medication order for Hydroxyzine. This Rule was cited during the compliance inspection conducted on June 5, 2024. A letter, dated June 12, 2024, stated “Enclosed is a copy of the Statement of Deficiencies (SOD), which describes the violations the Department found at the facility. Because the case has been referred to the Enforcement Team, the Department is not requesting a WRITTEN Plan of Correction (POC) at this time. However, the Department requires that you make immediate corrections of violations that present a threat to the health or safety of a client, resident, patient or agency personnel and still requires that you make corrections to all violations noted in the SOD.” Date permanent correction will be complete:

Rule: A. An administrator shall ensure that: 7. A resident does not: a. Use or have access to any
Evidence: Based on documentation review, record review, and interview, the administrator failed materials, furnishings, or equipment or participate in any activity or treatment that may present a threat to the resident’s health or safety based on the resident’s documented diagnosis, treatment needs, developmental levels, social skills, verbal skills, or personal history; or to ensure a resident did not have access to any materials to present a threat to the resident’s health or safety based on the resident’s documented personal history. The deficient practice posed a risk as a resident had access to marijuana while admitted into a behavioral health residential facility in contradiction with their behavioral health issues.

Findings:

1. A review of Department documentation revealed BH6115 was licensed as a behavioral health residential facility for individuals under 18 years of age (children).

2. A review of facility documentation revealed an incident report (dated September 16, 2024). The incident report stated “. While . @ park member used a friends vape pen to smoke marijuana. Member was on the basketball court playing with school mates who offered [R3] & another client the vape pen- . member was tested the next day which indicated positive for THC.”

3. A review of facility documentation revealed an incident report (dated September 22, 2024). The incident report stated “. Resident #1 came and advised me that [R3] was smoking a vape pen in the room they share. Resident #1 advised me that [R3] still had it and it was hidden in the room. Upon room search I located a weed vape . When confronted [R3] claimed I planted it there or Resident #1 did. Vape is the same brand of previous on confiscated from [R3] 2 weeks ago.”

4. A review of R3’s medical record revealed a behavioral health assessment (dated in 2024). The assessment stated ” . Started smoking weed at an early age instead of wanting to take medication. Drug of choice: weed.”

5. In an interview, E1 reported R3 must have accessed the marijuana from school. E1 reported searches are conducted using a metal wand, however, residents become creative to avoid detection.

6. In an interview, E1 acknowledged R3 had access to materials to present a threat to the resident’s health or safety based on the resident’s documented personal history. Date permanent correction will be complete:

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

6. Assistance in the self-administration of medication provided to a resident: a. Is in compliance with an order, and
Evidence: Based on record review, observation, and interview, the administrator failed to ensure assistance in the self-administration of medication provided to a resident was in compliance with an order, for one of three current residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper assistance in the self-administration of medication.

Findings:

1. A review of R1’s (admitted in 2024) medical record revealed a treatment plan (dated in 2024). The treatment plan revealed R1 received assistance in the self-administration of medication.

1.” However, the document was not signed by a medical practitioner.

5. In an interview, E1 reported R1’s medication orders were sent straight to the pharmacy. E1 reported a signed medication order for R1’s Hydroxyzine was not available for review.

6. In an interview, E1 acknowledged assistance in the self- administration of medication provided to R1 was not in compliance with an order. This Rule was cited during the compliance inspection conducted on June 5, 2024. A letter, dated June 12, 2024, stated “Enclosed is a copy of the Statement of Deficiencies (SOD), which describes the violations the Department found at the facility. Because the case has been referred to the Enforcement Team, the Department is not requesting a WRITTEN Plan of Correction (POC) at this time. However, the Department requires that you make immediate corrections of violations that present a threat to the health or safety of a client, resident, patient or agency personnel and still requires that you make corrections to all violations noted in the SOD.” Date permanent correction will be complete:

Rule: A. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that:

1. The premises and equipment are: a. Maintained in a condition that allows the premises and equipment to be used for the original purpose of the premises and equipment; b. Cleaned and, if applicable, disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection; and c. Free from a condition or situation that may cause a resident or other individual to suffer physical injury;
Evidence: Based on observation, record review, and interview, the administrator failed to ensure the premises was maintained in a condition that allowed the premises to be used for the original purpose and free from a condition or situation that may cause a resident or other individual to suffer physical injury. Findings include:

1. The Compliance Officer observed the doorknob for R1’s bedroom door was missing.

2. The Compliance Officer observed a closet in R1’s bedroom. The Compliance Officer observed a metal support bracket in the middle of the closet. However, the support bracket did not give way when the Compliance Officer applied downward pressure.

3. In an interview, E1 reported the doorknob was removed because R1 will lock the door and try to cause self-harm.

4. The Compliance Officer observed a closet in R2’s bedroom. The Compliance Officer observed a metal support bracket in the middle of the closet. However, the support bracket did not give way when the Compliance Officer applied downward pressure.

5. A review of R1’s (admitted in 2024) medical record revealed a document titled “Client Intake Assessment Packet” (date unavailable). The document stated ” . Current Behavior Concerns: (circle all that apply) Self- Harm” with “Self-Harm” circled.

6. A review of R1’s medical record revealed a nursing assessment titled “Initial Health Screen” (dated in 2024). The document stated ” . Tiny scars from self hurt.” 7. A review of R2’s (admitted in 2024) medical record revealed an untitled document (dated in 2024). The document stated ” . [R2] was referred to . for suicidal ideation, self-harm, and aggression. . [Parent] shared that information on referral stating that member was hospitalized for suicidal ideation and self-harming behaviors .” 8. In an interview, the findings were reviewed with E1 and no additional comments or statements were provided regarding the findings. Date permanent correction will be complete:

Findings:

Compliance (Annual) on 6/19/2023

Rule: A.R.S.§ 36-411. Residential care institutions; nursing care institutions; home health agencies; fingerprinting requirements; exemptions; definitions A. Except as provided in subsection F of this section, as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services and who have not been subject to the fingerprinting requirements of a health professional’s regulatory board pursuant to title 32 shall have valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article

Findings:

1. A review of E6’s (hired in 2019) personnel record revealed a fingerprint clearance card, issued on July 26, 2016 and expired on July 26, 2022. However, documentation of a valid fingerprint clearance card was not available for review.

2. A review of the Arizona Department of Public Safety (DPS) fingerprint verification website revealed E6’s card was issued on July 26, 2016 and expired on July 26, 2022.

3. A review of the Arizona Department of Public Safety (DPS) fingerprint verification website revealed E6 applied for a new fingerprint clearance card on April 22, 2022. However, the status was “closed.”

4. In an interview, E1 acknowledged E6’s fingerprint clearance card had expired. E1 reported to be unaware E6 needed a new fingerprint clearance card since E6 lived in another state and did not come to the facility to provide services. Date permanent correction will be complete: 2023-08-28

Findings:

1. A review of facility documentation revealed a training program for fall prevention and fall recovery was not available for review.

2. A review of E1’s, E2’s, E3’s, E5’s and E6’s personnel records revealed initial training and continued competency training in fall prevention and fall recovery was not available for review.

3. In an interview, E1 acknowledged a training program for fall prevention and fall recovery training was not available for review. E2 reported to be unaware of the requirement. Date permanent correction will be complete: 2023-08-10

Rule: A. A governing authority shall: 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 administrator and identify the name and qualifications of the new administrator.
Evidence: Based on documentation review and interview, the governing authority failed to notify the Department according to A.R.S. \’a7 36-425(I) when there was a change in the administrator and identify the name and qualifications of the new administrator.

Findings:

1. A review of Department documentation revealed E7 was the facility’s administrator during the on-site inspections conducted on May 31, 2022 and on November 10, 2022.

2. In an interview, E1 reported E8 was the facility’s administrator. E1 stated E8 had been the administrator “for a good while.” E1 reported to be unsure if anyone from the facility ever submitted documentation to the Department to notify the Department of the administrator change. E1 acknowledged E1 was unable to provide any documentation showing the Department was notified when E8 became the administrator. Date permanent correction will be complete: 2023-08-28

Rule: G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes:

3. Documentation of: h. Cardiopulmonary resuscitation training, if required for the individual according to R9-10- 703(C)(1)(e);
Evidence: Based on record review, documentation review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of cardiopulmonary resuscitation (CPR) training, for one of six personnel members sampled. The deficient practice posed a risk if a personnel member was unable to perform CPR.

Findings:

1. A review of E2’s personnel record revealed documentation of first aid and CPR training, dated February 22. 2023. However, the first aid and CPR training card was from an online program.

2. A review of facility documentation revealed a daily staffing schedule, dated “Mon 6/19 – Sun 6/25.” The schedule revealed E2 worked the following shifts: -Monday June 19 – 11:00 PM – 8:00 AM -Tuesday June 20 – 11:00 PM – 8:00 AM -Wednesday June 21 – 11:00 PM – 8:00 AM -Thursday June 22 – 11:00 PM – 8:00 AM

3. A review of the facility’s policies and procedure, dated May 25, 2023, revealed a policy titled, “Personnel Training.” The policy stated, “b. No online training will be acceptable. All CPR training must be completed in person.”

4. In an interview, E1 acknowledged E2’s CPR training had been completed online and did not include a demonstration. Date permanent correction will be complete: 2023-08-28

1. At least one personnel member who is present at the behavioral health residential facility during hours of operation of the behavioral health residential facility, and
Evidence: Based on documentation review, record review, and interview, the administrator failed to ensure at least one personnel member present at the behavioral health facility during hours of operation had cardiopulmonary resuscitation (CPR) training, for one of two behavioral health technicians sampled. The deficient practice posed a risk if an employee was unable to meet a resident’s needs during an emergency, accident, or injury. Findings include:

1. A review of the facility’s policies and procedure, dated May 25, 2023, revealed a policy titled, “Personnel Training.” The policy stated, “II. Policy: A. Cardiopulmonary Resuscitation (CPR)a. All staff members shall complete and have documentation of the completion of a nationally recognized Cardio- Pulmonary Resuscitation (CPR) class. b. No online training will be acceptable. All CPR training must be completed in person.c. Training must be completed every 2 years.”

2. A review of facility documentation revealed a daily staffing schedule, dated “Mon 6/19 – Sun 6/25.” The schedule revealed E2 worked the following shifts alone: -Monday June 19 – 11:00 PM – 8:00 AM -Tuesday June 20 – 11:00 PM – 8:00 AM -Wednesday June 21 – 11:00 PM – 8:00 AM -Thursday June 22 – 11:00 PM – 8:00 AM

3. A review of E2’s personnel record revealed documentation of first aid and CPR training, dated February 22, 2023. However, the CPR training card was from an online program.

4. In an interview, E1 acknowledged E2’s CPR training card was from an online program. E1 acknowledged E2 worked shifts at the facility alone. Date permanent correction will be complete: 2023-08-28

Findings:

Rule: A. An administrator shall ensure that:

6. Except as provided in subsection (E)(1)(a), a medical practitioner performs a medical history and physical examination or a registered nurse performs a nursing assessment on a resident within 30 calendar days before admission or within 72 hours after admission and documents the medical history and physical examination or nursing assessment in the resident’s medical record within 72 hours after admission;
Evidence: Based on record review and interview, the administrator failed to ensure a medical practitioner performed a medical history and physical examination or a registered nurse performed a nursing assessment on a resident within 30 calendar days before admission or within 72 hours after admission, for one of two residents sampled. The deficient practice posed a risk as this information was required for the development and implementation of a treatment plan, per R9-10-708.A.1. Findings include:

1. A review of R1’s (admitted in 2023) medical record revealed a nursing assessment was completed on January 31, 2023. However, the nursing assessment was not completed within 30 calendar days before admission or within 72 hours after admission.

2. In an interview, E1 acknowledged R1’s nursing assessment was not completed within 30 calendar days before admission or within 72 hours after admission. Date permanent correction will be complete: 2023-08-28

Findings:

1. A review of R1’s (admitted in 2023) medical record revealed an undated “Client Intake Assessment Packet. ” However, the document did not contain a signature of who conducted the assessment, and did not contain a signature and date from a BHP who reviewed the behavioral health assessment.

2. In an interview, E1 acknowledged the BHP did not review and sign the behavioral health assessment for R1 within 24 hours. E1 reported R1’s assessment was completed by E2, a BHT. Date permanent correction will be complete: 2023-08-28

Rule: A. An administrator shall ensure that: 13. Except as provided in subsection (E)(1)(d), a resident provides
Evidence: of freedom from infectious tuberculosis: a. Before or within seven calendar days after the resident’s admission, and b. As specified in R9-10-113. Evidence Based on record review and interview, the administrator failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident’s admission, for one resident sampled who was admitted in 2023. The deficient practice posed a TB exposure risk to residents. Findings:

1. A review of R1’s (admitted in 2023) medical record revealed evidence of freedom from infectious TB was not available for review. Based on R1’s date of admission, the evidence was required.

2. In an interview, E1 acknowledged R1’s medical record did not provide evidence of freedom from infectious TB before or within seven calendar days after R1’s admission. Date permanent correction will be complete: 2023-08-28

Findings:

Rule: B. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that:

Findings:

1. A review of Department documentation revealed the license for BH6115 was effective May 11, 2020.

2. A review of facility documentation revealed an undated disaster plan. However, an annual review of the disaster plan was not available for review.

3. In an interview, E1 acknowledged the facility had not reviewed the disaster plan in the last 12 months. Date permanent correction will be complete: 2023-08-28

Rule: B. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that:

Findings:

1. A review of Department documention revealed the license for BH6115 was effective on May 11, 2020.

2. A review of a daily staffing schedule dated “Mon 6/19 – Sun 6/25” revealed the facility maintained three shifts: 7:00 AM to 1:00 PM (first), 1:00 PM to 11:00 PM (second) and 11:00 PM to 8:00 AM (varied hours range from 7:00 AM to 8:00 AM on different days.)

3. A review of facility documentation revealed disaster drills were not available for review.

4. In an interview, E1 reported the facility maintained three shifts that varied from times, based on personnel availability. E1 acknowledged disaster drills were not conducted on each shift at least once every three months. Technical assistance was provided on this Rule during the onsite compliance inspection conducted on May 31, 2022 and this Rule was cited durin the onsite compliance inspection conducted on April 30, 2021. Date permanent correction will be complete: 2023-08-28

Rule: B. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that:

5. An evacuation drill for employees and
Evidence: Based on documentation review and interview, the administrator failed to ensure an evacuation drill for employees and residents on the premises was conducted at least once residents on the premises is conducted at least once every six months on each shift; every six months on each shift. The deficient practice posed a risk if employees were unable to implement a disaster plan, and the Department was unable to determine substantial compliance during the inspection.

Findings:

1. A review of Department documention revealed the license for BH6115 was effective on May 11, 2020.

3. A review of facility documentation revealed the following evacuation drills were completed: -May 26, 2022 – 1st shift -November 8, 2022 – 3rd shift – November 9, 2022 – 2nd shift -November 10, 2022 – 3rd shift -May 12, 2023 – 3rd shift

4. In an interview, E1 reported the facility maintained three shifts that varied from times, based on personnel availability. E1 acknowledged evacuation drills had not been conducted at least once every six months on each shift. Date permanent correction will be complete: 2023-08-28

Rule: A. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 10. Hot water temperatures are maintained between 95° F and 120° F in the areas of the behavioral health residential facility used by residents;
Evidence: Based on observation and interview, the administrator failed to ensure hot water temperatures were maintained between 95\’b0 F and 120\’b0 F in the areas of the behavioral health residential facility used by residents. The deficient practice posed a burn risk to residents.

Findings:

1. The Compliance Officer observed the hot water temperature at the kitchen sink to be 133.7\’b0 F using a Department-issued thermometer.

2. The Compliance Officer observed the hot water temperature at the hallway bathroom sink to be 138.7\’b0 F using a Department- issued thermometer.

3. In an interview, E1 acknowledged the temperature of the hot water in the facility was not maintained between 95\’b0 F and 120\’b0 F. Date permanent correction will be complete: 2023-08-28

Complaint on 4/7/2025

Rule: C. An administrator shall ensure that:

Findings:

Rule: C. An administrator shall ensure that:

5. Unless otherwise stated: a. Documentation required by this Article is provided to the Department within two hours after a Department request; and
Evidence: Date permanent correction will be complete:

Findings:

Rule: B. An administrator shall ensure that:

Findings:

Rule: G. An administrator shall ensure that a personnel record is maintained for each
Evidence: personnel member, employee, volunteer, or student that includes:

3. Documentation of: e. The individual’s compliance with requirements in A.R.S. §§ 36-411, 36-411.01, and 36-425.03, as applicable; Date permanent correction will be complete:

Findings:

Rule: G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes:

Findings:

Rule: G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes:

3. Documentation of: j.
Evidence: of freedom from infectious tuberculosis, if required for the individual according to subsection (F). Evidence Date permanent correction will be complete: 2025-04-07

Findings:

Rule: C. An administrator shall ensure that a resident’s medical record contains: 9. Orders;
Evidence: Date permanent correction will be complete: 2025-04-07

Findings:

Rule: A. An administrator shall ensure that: 7. A resident does not: a. Use or have access to any
Evidence: materials, furnishings, or equipment or participate in any activity or treatment that may present a threat to the resident’s health or safety based on the resident’s documented diagnosis, treatment needs, developmental levels, social skills, verbal skills, or personal history; or Date permanent correction will be complete: 2025-04-07

Findings:

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

6. Assistance in the self-administration of medication provided to a resident: a. Is in compliance with an order, and
Evidence: Date permanent correction will be complete: 2025-04-07

Findings:

Rule: A. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that:

Findings:

Complaint on 11/10/2022

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

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

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

6. Maintain a copy of the documented information required in subsection (I)(5) and any other information obtained during
Evidence: Based on record review, documentation review, and interview, the manager failed to ensure, if a manager had a reasonable basis, according to A.R.S. \’a7 13-3620 or 46-454, to believe abuse had occurred on the premises or while a resident was receiving services from a behavioral health residential facility’s employee or personnel member, the administrator complied with all the requirements of this rule. The deficient practice posed a health and safety risk to residents if an investigation was not completed and documented, as required. A.R.S. \’a7 13- 3620(A) Any person who reasonably believes that a minor is or has been the victim of physical injury, abuse, child abuse, a reportable offense or neglect that appears to have been inflicted on the minor by other than accidental means or that is not explained by the available medical history as being accidental in nature or who reasonably believes there has been a denial or deprivation of necessary medical treatment or surgical care or nourishment with the intent to cause or allow the death of an infant who is protected under section 36-2281 shall immediately report or cause reports to be made of this information to a peace officer, to the department of child safety or to a tribal law enforcement or social services agency for any Indian minor who resides on an Indian reservation, except if the report concerns a person who does not have care, custody or control of the minor, the report shall be made to a peace officer only.

Findings:

1. In documentation review, the Department received notification of an allegation of suspected abuse by R1 towards R2.

2. In the investigation for at least 12 months after the date the investigation was initiated. documentation review, the facility had a documented “Incident Report for Children in Custody of (Facility) or Department of Child Safety (DCS).” The report documented on October 23, 2022, “. resident touched roommate butt and admitted to it and said. will do it again.” A second incident report dated October 23, 2022, documented “after earlier issues resident went AWOL. Goodyear PD and management notified.”

3. In an interview, E1 reported R2 informed E4 that R1 poked (R2’s) “butt”. E4 reported the incident to E1. The residents were separated, and R1 was upset at R2 for “narcing (R1) out.” R1 eloped from the facility. The police were contacted, picked up R1 (had to “tackle” the resident) and contacted emergency services who transported R1 to Phoenix Children’s Hospital.

4. In an interview with E1 and E2, the surveyor requested to review the facility’s documentation of the investigation of the suspected abuse; including the dates, times, and description of the suspected abuse, neglect, or exploitation; a description of any injury to the resident related to the suspected abuse and any change to the resident’s physical, cognitive, functional, or emotional condition; the names of witnesses to the suspected abuse; and the actions taken by the manager to prevent the suspected abuse from occurring in the future. E1 reported an incident report had been completed by E4; however, acknowledged an investigation of the suspected abuse had not been documented per the rule requirements. Date permanent correction will be complete: 2022-12-19

Rule: G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes:

3. Documentation of: g. If the individual is a behavioral health technician, clinical oversight required in R9-10-115;
Evidence: Based on record review, and interview, for three of three behavioral health technicians (BHT) reviewed, the administrator failed to ensure a personnel record was maintained for each BHT that included documentation of clinical oversight required in R9-10-115. The deficient practice posed a risk to the health and safety of residents if clinical oversight was not provided to non licensed staff providing services, to ensure a resident’s needs were being met.

Findings: “Clinical oversight” means: a. Monitoring the behavioral health services provided by a behavioral health technician to ensure that the behavioral health technician is providing the behavioral health services according to the health care institution’s policies and procedures and, if applicable, a patient’s treatment plan; b. Providing on-going review of a behavioral health technician’s skills and knowledge related to the provision of behavioral health services; c. Providing guidance to improve a behavioral health technician’s skills and knowledge related to the provision of behavioral health services; and d. Recommending training for a behavioral health technician to improve the behavioral health technician’s skills and knowledge related to the provision of behavioral health services. R9-10- 115.4. A behavioral health technician receives clinical oversight at least once during each two week period, if the behavioral health technician provides services related to patient care at the health care institution during the two week period. Findings Include:

1. In record review, the personnel records for E1, E4, and E5, who were BHTs, included documentation of “Staff Training,” dated September 5, 2022, and October 3, 2022, and “Clinical Oversight,” on August 8, 2022, provided by E3. Based upon documentation of services provided, the employees were required to receive clinical oversight by a Behavioral Health Professional.

2. In record review, the medical record for R1 included documentation E1 completed and signed the BH assessment and treatment plans for R1, and E4 and E5 provided group counseling sessions for R1.

3. In an interview with E1 and E2, E1 reported E1 completed the BH assessments and treatment plan for the residents, and the BHT’s conducted weekly counseling sessions with the residents. E1 reported clinical oversight was provided once a month, and acknowledged the requirement for clinical oversight wasn’t met. Date permanent correction will be complete: 2022-12-19

Rule: A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that:

4. Includes: a. The resident’s presenting issue;
Evidence: Based on record review and interview, for one resident reviewed, the administrator failed to ensure a treatment plan was developed which included the resident’s presenting issue.

Findings:

1. In record review, R1’s medical record included a behavioral health assessment dated January 13, 2022. The behavioral health assessment included a section titled Diagnoses, and included AXIS codes only. R1’s record included a treatment plan dated May 31, 2022, and October 17, 2022. Neither treatment plan included the resident’s presenting issues.

2. In an interview, E1 and E2 reported R1’s presenting issues as defiant behavior, history of danger to self, cruelty to animals. E1 and E2 acknowledged the treatment plan did not include R1’s presenting issues. Date permanent correction will be complete: 2022-12-19

Rule: A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that:

5. If the treatment plan was completed by a behavioral health technician, is reviewed and signed by a behavioral health professional within 24 hours after the completion of the treatment plan to ensure that the treatment plan is complete and accurate and meets the resident’s treatment needs; and
Evidence: Based on interview, record review, and documentation review, for one resident reviewed, the administrator failed to ensure a treatment plan developed by a behavioral health technician (BHT) was reviewed and signed by a behavioral health professional (BHP). The deficient practice posed a risk if the facility did not have a qualified behavioral health professional acknowledge and sign a resident’s treatment plan.

Findings:

1. In record review, R1’s medical record included a treatment plan dated May 31, 2022. The treatment plan was developed and signed by E1; however, was not signed by a BHP.

2. In an interview, E1 acknowledged a BHP did not sign R1’s treatment plan. Date permanent correction will be complete: 2022-12-19

Rule: B. An administrator shall ensure that:

1. A request for participation in developing a resident’s treatment plan is made to the resident or the resident’s representative,

2. An opportunity for participation in developing the resident’s treatment plan is provided to the resident or the resident’s representative, and

3. The request in subsection (B)(1) and the opportunity in subsection (B)(2) are documented in the resident’s medical record.
Evidence: Based on record review, and interview, for one resident reviewed, the administrator failed to ensure a request for participation in developing a resident’s treatment plan and an opportunity for participation in developing a resident’s treatment plan was provided to a resident’s representative. The deficient practice posed a risk to a minor resident if a resident’s representative/guardian was not provided a request and an opportunity to participate in a minor child’s treatment planning.

Findings:

1. In record review, R1’s medical record included treatment plans dated May 31, 2022, and October 17. 2022. Neither treatment plan included documentation R1’s representative/guardian was provided a request and an opportunity to participate in developing a treatment plan for R1.

2. In an interview, the findings were reviewed with E1 and E2, who acknowledged R1 was a minor with a representative/guardian, and R1’s medical record did not include documentation the representative/guardian was provided a request or an opportunity to participate in R1’s treatment planning. Date permanent correction will be complete: 2022-12-19

Rule: B. An administrator shall ensure that counseling is:

2. Provided according to the frequency and number of hours identified in the resident’s treatment plan, and
Evidence: Based on record review and interview, for one resident reviewed, the administrator failed to ensure counseling was provided according to the frequency identified in the resident’s treatment plan. The deficient practice posed a risk if a resident did not receive treatment to cure, improve, or palliate their behavioral health issue at the health care institution.

Findings:

1. In record review, R1’s medical record included a treatment plan dated May 31, 2022, and October 17, 2022. R1’s treatment plans documented the following: – “Participate in 1 on 1’s, group therapy, and weekly appointments with trauma therapist 5/7 days” – “Participate in therapy, groups, and meetings 5/7 days” – “Schedule and log in for 1 on 1 counseling and conduct group therapy. discuss issues and concerns in therapy, share, communicate, learn through counseling, groups, staff and coping skills 1 hour weekly, 1 hour group weekly”

2. In record review, R1’s medical record included documentation of “group notes” sessions for the following dates: – June 9, 2022 for 40 minutes – September 22 for 45 minutes – October 8 for 35 minutes – October 8 for 30 minutes – October 27 for 1 hour – October 30, 2022 for

1.5 hours – November 2, 2022 for 45 minutes

3. In record review, R1’s medical record included documentation of a “Therapy Log,” form which included documentation R1 received therapy from O1 approximately twice monthly until September 28, 2022, and no documentation of therapy since.

4. In an interview, the findings were reviewed with E1 and E2. E1 reported the residents received group counseling once weekly from a BHT, one to one counseling daily from BHT’s, and R1 received off site therapy services (until the therapy agency closed). The facility was working on obtaining a new therapist for R1. E1 and E2 acknowledged counseling services were not provided and documented according to the frequency identified in the resident’s treatment plan. Date permanent correction will be complete: 2022-12-19

Rule: C. An administrator shall ensure that:

Findings:

1. In record review, R1’s medical record included a treatment plan dated May 31, 2022 and October 17, 2022. R1’s treatment plans documented treatment goals as “will learn and implement coping skills that result in the reduction of physical aggression, anxiety and the need to lash out physically. will follow all medication directies. will bathe daily. brush teeth, wash face. will assist in setting up therapeutic goals and using them daily. will request assistance from . team .. whenever. feels. needs help. will learn to communicate honestly with . team, staff and mother.” – “Participate in 1 on 1’s, group therapy, and weekly appointments with trauma therapist 5/7 days” – “Participate in therapy, groups, and meetings 5/7 days” – “Schedule and log in for 1 on 1 counseling and conduct group therapy. discuss issues and concerns in therapy, share, communicate, learn through counseling, groups, staff and coping skills 1 hour weekly, 1 hour group weekly”

1.5 hours – November 2, 2022 for 45 minutes

3. In an interview, the findings were reviewed with E1 and E2. E1 reported the residents received group counseling on site once weekly from a BHT. E1 and E2 acknowledged the counseling sessions documented in the resident’s record did not include documentation of the treatment goals addressed. Date permanent correction will be complete: 2022-12-19

ANIMALS FACILITATING ADOLESCENTS AND CHILDREN
39213 South Wild Hardt Way, Suite A, Marana, AZ 85658

Compliance (Annual) on 2/8/2023

Rule: A. An administrator shall ensure that: 10. If a behavioral health assessment that complies with the requirements in this Section is received from a behavioral health provider other than the behavioral health residential facility or if the behavioral health residential facility has a medical record for the resident that contains a behavioral health assessment that was completed within 12 months before the date of the resident’s current admission: b. The review and update of the resident’s assessment information is documented in the resident’s medical record within 48 hours after the review is completed;
Evidence: Based on record review and interview, the administrator failed to ensure a behavioral health assessment is in compliance with the requirements in this Section, received from a behavioral health provider other than the behavioral health residential facility, was reviewed, updated, and documented in the resident’s medical record within 48 hours after the review was completed, for one of two residents sampled.

Findings:

1. A review of R2’s medical record revealed a behavioral health assessment (dated September 6, 2022) from a behavioral health provider other than BH4395. However, documentation of a review and update of R2’s assessment information was not available for review.

2. In an interview, E1 reported R2’s behavioral health assessments were reviewed by E2. However, E2 did not document E2 reviewed R2’s assessment information. Date permanent correction will be complete: 2023-03-12

Compliance (Annual) on 2/8/2023

Findings:

Change of Service on 11/14/2023

No violations noted.

Compliance (Annual) on 1/9/2024

Rule: A. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that:

1. The premises and equipment are: c. Free from a condition or situation that may cause a resident or other individual to suffer physical injury;
Evidence: Based on observation, record review, and interview, the administrator failed to ensure the premises was free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a risk to the physical health and safety of residents. Findings include:

1. The Compliance Officer observed a bathroom in the facility with a grab bar attached to the wall, next to the shower. The Compliance Officer observed an unsecured steak knife in the dish basket in the kitchen.

2. A review of R2’s medical record revealed R2 had self-harming behaviors under “Summary of Issues Identified” in R2’s initial psychosocial assessment.

3. In an interview, E1 acknowledged the grab bar in the bathroom and the unsecured steak knife. E1 reported knives are always locked up. However, E1 had forgotten to secure the knife on the day of the inspection. E1 acknowledged the potential risk to the physical health and safety of residents. Date permanent correction will be complete: 2024-01-26

Findings:

Compliance (Annual) on 1/6/2025

No violations noted.

ARIZONA CHILDREN’S GROUP LLC
142 West Ivanhoe Place, Chandler, AZ 85225

Complaint;Compliance (Annual) on 3/3/2023

2. Verify the current status of a person’s fingerprint clearance card.
Evidence: Based on record review and interview, the owner failed to ensure compliance with A.R.S. \’a7 36-411(C)(1), for three of nine employees sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not in the personnel records during the inspection, and the documentation was not provided within two hours after a Department request.

Findings: A.R.S. \’a7 36-411(C) (1) Owners shall make documented, good faith efforts to: Contact previous employers to obtain information or recommendations that may be relevant to a person’s fitness to work in a residential care institution, nursing care institution or home health agency.

1. A review of E3’s (hired in 2022) personnel record revealed documentation of compliance with A.R.S. \’a7 36-411(C)(1) was not available for review.

2. A review of E5’s (hired in 2022) personnel record revealed documentation of compliance with A.R.S. \’a7 36-411(C)(1) was not available for review.

3. A review of E7’s (hired in 2021) personnel record revealed documentation of compliance with A.R.S. \’a7 36-411(C)(1) was not available for review.

4. In a joint interview, E1 and E2 acknowledged documentation of compliance with A.R.S. \’a7 36-411(C)(1) for E3, E5, and E7 was not available for review. Date permanent correction will be complete: 2023-08-03

Rule: 36-425.03. Children’s behavioral health programs; personnel; fingerprinting requirements; exemptions; definitions E. Children’s behavioral health program personnel shall certify on forms that are provided by the department and notarized that they are not awaiting trial on or have never been convicted of or admitted in open court or pursuant to a plea agreement to committing any of the offenses listed in section 41-1758.03, subsection B or C in this state or similar offenses in another state or jurisdiction.
Evidence: Based on record review and interview, the children’s behavioral health program personnel failed to certify and notarize on forms provided by the department they were not awaiting trial on or had never been convicted of or admitted in open court or pursuant to a plea agreement to committing any of the offenses listed in section 41-1758.03, subsection B or C in this state or similar offenses in another state or jurisdiction. The deficient practice posed a risk if E2, E3, E4, E5, E6, E7, and E8 were a danger to a vulnerable population, the Department was unable to determine substantial compliance as the documentation was not in the personnel record during the inspection, and the documentation was not provided within two hours after a Department request.

Findings:

1. A review of E2’s (hired in 2021) personnel record revealed a notarized form provided by the department certifying E2 was not awaiting trial on or had never been convicted of or admitted in open court or pursuant to a plea agreement to committing any of the offenses listed in section 41- 1758.03, subsection B or C in this state or similar offenses in another state or jurisdiction was not available for review.

2. A review of E3’s (hired in 2022) personnel record revealed a notarized form provided by the department certifying E3 was not awaiting trial on or had never been convicted of or admitted in open court or pursuant to a plea agreement to committing any of the offenses listed in section 41-1758.03, subsection B or C in this state or similar offenses in another state or jurisdiction was not available for review.

3. A review of E4’s (hired in 2021) personnel record revealed a notarized form provided by the department certifying E4 was not awaiting trial on or had never been convicted of or admitted in open court or pursuant to a plea agreement to committing any of the offenses listed in section 41-1758.03, subsection B or C in this state or similar offenses in another state or jurisdiction was not available for review.

4. A review of E5’s (hired in 2022) personnel record revealed a notarized form provided by the department certifying E5 was not awaiting trial on or had never been convicted of or admitted in open court or pursuant to a plea agreement to committing any of the offenses listed in section 41-1758.03, subsection B or C in this state or similar offenses in another state or jurisdiction was not available for review.

5. A review of E6’s (hired in 2020) personnel record revealed a notarized form provided by the department certifying E6 was not awaiting trial on or had never been convicted of or admitted in open court or pursuant to a plea agreement to committing any of the offenses listed in section 41-1758.03, subsection B or C in this state or similar offenses in another state or jurisdiction was not available for review.

6. A review of E7’s (hired in 2021) personnel record revealed a notarized form provided by the department certifying E7 was not awaiting trial on or had never been convicted of or admitted in open court or pursuant to a plea agreement to committing any of the offenses listed in section 41-1758.03, subsection B or C in this state or similar offenses in another state or jurisdiction was not available for review. 7. A review of E8’s (hired in 2021) personnel record revealed a notarized form provided by the department certifying E8 was not awaiting trial on or had never been convicted of or admitted in open court or pursuant to a plea agreement to committing any of the offenses listed in section 41-1758.03, subsection B or C in this state or similar offenses in another state or jurisdiction was not available for review. 8. In a joint interview, E1 and E2 acknowledged the personnel members had not certified on notarized forms they were not awaiting trial on or had never been convicted of or admitted in open court or pursuant to a plea agreement to committing any of the offenses listed in section 41-1758.03, subsection B or C in this state or similar offenses in another state or jurisdiction. Date permanent correction will be complete 2023-08-15 Monitoring

Rule: 36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition A. Each health care institution shall develop and administer a training program for all staff regarding fall prevention and fall recovery. The training program shall include initial training and continued competency training in fall prevention and fall recovery. A health care institution may use information and training materials from the department’s Arizona falls prevention coalition in developing the training program.
Evidence: Based on documentation review, record review and interview, the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery to include initial training and continued competency training in fall prevention and fall recovery. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not available during the inspection, and the documentation was not provided within two hours after a Department request.

Findings:

1. A review of the facility’s electronic policies and procedures revealed a policy titled “Staff Qualifications, Training, and Responsibilities” (dated January 1, 2021). However, evidence of a fall prevention and fall recovery training program was not available for review.

2. A review of E2’s, E3’s, E4’s, E5’s, E6’s, E7’s and E8’s personnel records revealed documentation of initial training or continued competency training in fall prevention and fall recovery was not available for review.

3. In a joint interview, E1 and E2 acknowledged the facility had not developed and administered a training program for all staff regarding fall prevention and fall recovery. Date permanent correction will be complete: 2023-10-18

Rule: B. An administrator:

3. Except as provided in subsection (A)(6), designates, in writing, an individual who is present on the behavioral health residential facility’s premises and accountable for the behavioral health residential facility when the administrator is not present on the behavioral health residential facility’s premises.
Evidence: Based on observation, record review, documentation review, and interview, the administrator failed to designate, in writing, an individual who was present on the behavioral health residential facility’s premises and accountable for the behavioral health residential facility when the administrator was not present on the behavioral health residential facility’s premises. The deficient practice posed a risk as O1 was not present on the premises and accountable when E1 was not present on the premises, the Department was unable to determine substantial compliance as the documentation was not available during the inspection, and the documentation was not provided within two hours after a Department request.

Findings:

1. The Compliance Officer observed E3 working, alone, on the premises when the Compliance Officer arrived at approximately 9:18 AM.

2. A review of E3’s (hired in 2022) personnel record revealed E3 was hired as a behavioral health paraprofessional (BHPP). However, documentation designating E3 to be present on the behavioral health residential facility’s premises and accountable for the behavioral health facility when the administrator was not present was not available for review.

3. The Compliance Officer observed E2 arrive on the premises at approximately 9:52 AM.

4. A review of E2’s (hired in 2021) personnel record revealed E2 was hired as the house manager.

5. The Compliance Officer observed E1 arrive on the premises at approximately 10:20 AM.

6. A review of the facility’s electronic policies and procedures revealed a policy titled “Administrator-Back-Up” (dated November 27, 2021). The policy stated “During the absence of the Administrator, a qualified designee will be the designated relief person who will assume the necessary Administrator responsibilities for the day-to-day operation of Arizona Children’s Group i [sic] the interim.I, [O1], accept the responsibility of Alternate Administrator for the agency in the absence of the above Administrator.” 7. In a joint interview, E1 and E2 acknowledged O1 was not present on the behavioral health residential facility’s premises and accountable for the behavioral health residential facility when E1 was not present on the behavioral health residential facility’s premises. Date permanent correction will be complete: 2023-06-01

Rule: C. An administrator shall ensure that:

1. Policies and procedures are established, documented, and implemented to protect the health and safety of a resident that: a. Cover job descriptions, duties, and qualifications, including required skills, knowledge, education, and experience for personnel members, employees, volunteers, and students;
Evidence: Based on documentation review and interview, the administrator failed to establish and document policies and procedures to protect the health and safety of a resident to cover qualification, including skills and knowledge for personnel members, employees, volunteers, and students. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees, the Department was unable to determine substantial compliance as the documentation was not available during the inspection, and the documentation was not provided within two hours after a Department request.

Findings:

1. A review of Department documentation revealed the facility’s perpetual license was effective on November 29, 2019.

2. A review of the facility’s electronic policies and procedures (dated November 27, 2021) revealed policies and procedures to include qualifications, including skills and knowledge were not available for review.

3. In a joint interview, E1 and E2 acknowledged policies and procedures were not established and documented to cover required skills and knowledge for personnel members, employees, volunteers, and students. Date permanent correction will be complete: 2023-11-30

Rule: C. An administrator shall ensure that:

1. A review of the facility’s electronic policies and procedures revealed a policy titled “CPR and First Aid” (dated November 27, 2021). The policy stated “Cardiopulmonary resuscitation (CPR). [sic] and First Aid Training certificates presented must be from and [sic] online [sic] competency course or in-person instruction, hands-on practice, and skills assessment.”

2. A review of E2’s personnel record revealed documentation of CPR and first aid training, issued on May 2, 2022 with an expiration date of May 2, 2024. The certificate stated “Online (Eligable for Skills Session within 90 days).” However, documentation to indicate the CPR training included a demonstration of the individual’s ability to perform CPR was not available for review.

3. A review of E6’s personnel record revealed documentation of CPR and first aid training from American Health Care Academy issued on April 2, 2021 with an expiration date of April 2, 2023. However, documentation to indicate the CPR training included a demonstration of the individual’s ability to perform CPR was not available for review.

4. A review of the American Health Care Academy website revealed courses were conducted online. The American Health Care Academy website stated “Learn CPR with our simple and easy-to-understand online CPR certification courses at American HealthCare Academy and be a lifesaver today.”

5. In a joint interview, E1 and E2 acknowledged E2’s amd E6’s CPR training did not include a demonstration of the individual’s ability to perform CPR, and the policy and procedure was not implemented. Date permanent correction will be complete: 2023-11-30

Findings:

Rule: C. An administrator shall ensure that:

1. Policies and procedures are established, documented, and implemented to protect the health and safety of a resident that: h. Cover first aid training;
Evidence: Based on documentation review, record review, and interview, the administrator failed to implement policies and procedures to protect the health and safety of a resident to cover first aid training The deficient practice posed a risk as standards expected of employees were not followed, the Department was unable to determine substantial compliance as the personnel records did not include the documentation during the inspection, and the documentation was not provided within two hours after a Department request.

Findings:

1. A review of the facility’s electronic policies and procedures revealed a policy titled “CPR and First Aid” (dated November 27, 2021). The policy stated “Upon hire, the Administrator, or designee, will make certain all employees providing direct care to individuals at the home and all staff partaking in outing with individuals including supervisors holds a current certificate in standard first aid and cardiopulmonary resuscitation (CPR) by obtaining copies of the certificate of completion.The Administrator, or designee, will ensure no employee or supervisor provides direct care in the home or participate in outings without current certificate in standard first aid and cardiopulmonary resuscitation (CPR).”

2. A review of E5’s (hired in 2022) personnel record revealed documentation of first aid training was not available for review.

3. In a joint interview, E1 and E2 acknowledged the facility’s policies and procedures to cover first aid training was not implemented. Date permanent correction will be complete: 2023-10-07

Rule: C. An administrator shall ensure that:

Findings:

1. A review of E3’s personnel record revealed E3 was hired as a behavioral health paraprofessional (BHPP). However, documentation designating E3 to be present on the behavioral health residential facility’s premises and accountable for the behavioral health facility when the administrator was not present was not available for review.

3. A review of E2’s personnel record revealed documentation of CPR and first aid training, issued on May 2, 2022 with an expiration date of May 2, 2024. The certificate stated “Online (Eligible for Skills Session within 90 days).” However, documentation to indicate the CPR training included a demonstration of the individual’s ability to perform CPR was not available for review.

4. A review of E6’s personnel record revealed documentation of CPR and first aid training from American Health Care Academy issued on April 2, 2021 with an expiration date of April 2, 2023. However, documentation to indicate the CPR training included a demonstration of the individual’s ability to perform CPR was not available for review.

5. A review of E5’s personnel record revealed documentation of first aid training was not available for review.

6. The Compliance Officer did not observe a posting of the location at which inspection reports were available for review or could be made available for review. 7. The Compliance Officer did not observe a posting of the calendar days and times when a resident could accept visitors or make telephone calls. 8. The Compliance Officer requested to review quality management documentation; however, documentation was not provided for review. 9. A review of E6’s personnel record revealed E6 was hired as the behavioral health professional. However, documentation of current contracted services including a description of the contracted services provided was not available for review. 10. A review of E2’s personnel record revealed E2 was hired as the house manager. However, verification of skills and knowledge was not available for review. 11. A review of E3’s personnel record revealed E3 was hired as a behavioral health paraprofessional. However, verification of skills and knowledge was not available for review. 12. A review of E4’s personnel record revealed E4 was hired as a behavioral health technician. However, verification of skills and knowledge was not available for review. 13. A review of E5’s personnel record revealed E2 was hired as a therapist/case manager. However, verification of skills and knowledge was not available for review. 14. A review of E6’s personnel record revealed E6 was hired as the behavioral health professional. However, verification of skills and knowledge was not available for review. 15. A review of E7’s personnel record revealed E7 was hired as a BHT. However, verification of skills and knowledge was not available for review. 16. A review of E8’s personnel record revealed E8 was hired as the registered nurse (RN). However, verification of skills and knowledge was not available for review. 17. A review of E2’s personnel record revealed E2 was hired as the house manager. However, documentation of education applicable to E2’s job duties was not available for review. 18. A review of E3’s personnel record revealed a job description for a behavioral health paraprofessional (BHPP). The job description stated “Qualifications and Education Requirements.Minimum of 21-years old; a High School Diploma or GED equivalency.” However, documentation of education was not available for review. 19. A review of E4’s personnel record revealed E4 was hired as a BHT. However, documentation of education applicable to E4’s job duties was not available for review. 20. A review of E5’s personnel record revealed E5 was hired as a therapist/case manager. However, documentation of education applicable to E5’s job duties was not available for review. 21. A review of E6’s personnel record revealed E6 was hired as the behavioral health professional. However, documentation of education applicable to E6’s job duties was not available for review. 22. A review of E7’s personnel record revealed a job description for a behavioral health technician (BHT). The job description stated “Education, Experience and Preferred Qualifications.Minimum of High School diploma or GED.” However, documentation of education was not available for review. 23. A review of E5s personnel record revealed documentation of a negative TB test was not available for review. 24. A review of facility documentation revealed a daily staffing schedule dated February 27, 2023 to March 5, 2023. However, documentation maintained for at least 12 months after the last date on the documentation was not available for review. 25. A review of the daily staffing schedule revealed the daily staffing schedule did not include documentation of the employees who worked each calendar day and the hours worked by each employee, and did not include on-call personnel members to include the behavioral health professional and registered nurse. 26. A review of R2’s medical record revealed a behavioral health assessment for R2 was not available for review. 27. A review of R3’s medical record revealed a behavioral health assessment for R3 was not available for review. 28. A review of R1’s medical record revealed documentation of freedom from infectious tuberculosis was not available for review. 29. A review of R2’s medical record revealed documentation of freedom from infectious tuberculosis was not available for review. 30. A review of R3’s medical record revealed documentation of freedom from infectious tuberculosis was not available for review. 31. A review of R2’s medical record revealed a treatment plan was not available for review. 32. A review of R3’s medical record revealed a treatment plan was not available for review. 33. A review of R1’s medical record revealed a treatment plan dated in February 2023. The treatment plan included various goals, objectives, and interventions. However, the treatment plan did not include the behavioral health services to be provided to R1. 34. The Compliance Officer observed a facility posting titled “CLIENT COPY OF CLIENT RIGHTS.” The document stated “Arizona Statutes R9-20-203 Department of Behavioral Health Licensure.require that you be informed of your rights as a client.” However, the requirements in subsection (B) and the resident rights in subsection (E) were not conspicuously posted on the premises. 35. A review of R1’s medical record revealed R1’s date of admission and discharge was not available for review. 36. A review of R2’s medical record revealed R2’s date of admission was not available for review. 37. A review of R3’s medical record revealed R3’s date of admission was not available for review. 38. A review of the facility’s electronic policies and procedures revealed a policy titled “Emergency and Safety Standards” (dated January 1, 2021). The policy stated “Arizona Children’s Group has entered into agreements or memorandums of understanding with a location designated as the evacuation site.Arizona Children’s Group has an agreement and a contract with relocation of residents in the event of an emergency evacuation.” However, th Date permanent correction will be complete: 2023-08-26

Rule: M. An administrator shall ensure that the following information or documents are conspicuously posted on the premises and are available upon request to a personnel member, employee, resident, or a resident’s representative:

2. The location at which inspection reports required in R9-10-720(C) are available for review or can be made available for review, and
Evidence: Based on observation and interview, the administrator failed to ensure the location at which inspection reports were available for review or could be made available for review was conspicuously posted on the premises. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not available during the inspection, and the documentation was not provided within two hours after a Department request.

Findings:

1. The Compliance Officer did not observe a posting of the location at which inspection reports were available for review or could be made available for review.

2. In a joint interview, E1 and E2 acknowledged the location at which inspection reports were available for review or could be made available for review was not posted at the time of the inspection. Date permanent correction will be complete: 2023-08-26

3. The calendar days and times when a resident may accept visitors or make telephone calls.
Evidence: Based on observation and interview, the administrator failed to ensure the calendar days and times when a resident may accept visitors or make telephone calls were conspicuously posted on the premises. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not available during the inspection, and the documentation was not provided within two hours after a Department request.

Findings:

1. The Compliance Officer did not observe a posting of the calendar days and times when a resident could accept visitors or make telephone calls.

2. In an interview, E1 acknowledged the calendar days and times when a resident may accept visitors or make telephone calls were not conspicuously posted on the premises. Date permanent correction will be complete: 2023-12-01

Rule: An administrator shall ensure that:

1. A plan is established, documented, and implemented for an ongoing quality management program that, at a minimum, includes: e. The frequency of submitting a documented report required in subsection (2) to the governing authority;
Evidence: Based on documentation review and interview, the administrator failed to ensure a plan was implemented for an ongoing quality management program to include the frequency of submitting a documented report required in subsection (2) to the governing authority. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided, the Department was unable to determine compliance as the documentation was not available during the inspection and was not provided within two hours after a Department’s request. Findings include:

1. A review of the facility’s policies and procedures revealed a policy titled “Quality Management Plan” (dated November 27, 2021). The policy stated “.Executive Leadership Team .Meeting Frequency: Semi- Weekly .Client Services Team .Frequency: Weekly .Clinical Services Team .Frequency: Quarterly .Risk Management/Safety Team .Frequency: Quarterly .Resident/Individual Rights Team .Frequency: Quarterly .”

2. The Compliance Officer requested to review quality management documentation; however, documentation was not provided for review.

3. In a joint interview, E1 and E2 acknowledged quality management documentation was not available for review. Date permanent correction will be complete: 2023-08-25

Findings:

Rule: An administrator shall ensure that:

2.
Evidence: Based on record review and interview, the Documentation of current contracted services is maintained that includes a description of the contracted services provided. administrator failed to ensure documentation of current contracted services included a description of the contracted services provided, for one behavioral health professional (BHP) sampled. The deficient practice posed a risk as the description of contracted services was not with an individual, the Department was unable to determine substantial compliance as the personnel record did not include the required documentation during the inspection, and the documentation was not provided within two hours after a Department request.

Findings:

1. A review of E6’s (hired in 2020) personnel record revealed E6 was hired as the BHP. However, documentation of current contracted services including a description of the contracted services provided was not available for review.

2. In a joint interview, E1 and E2 acknowledged E6’s documentation of current contracted services including a description of the contracted services to be provided with an individual was not available for review. Date permanent correction will be complete: 2023-06-14

Rule: B. An administrator shall ensure that:

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
Evidence: Based on record review and interview, the administrator failed to ensure a personnel member’s skills and knowledge were verified and documented before the personnel member provided behavioral health services, for seven of seven personnel members sampled. The deficient practice posed a risk if a personnel member was not qualified to work in a health care institution, the Department was unable to determine substantial compliance as the documentation was not in the personnel records during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: R9-10-101.167. “Personnel member” means, except as defined in specific Articles in this Chapter . . . an individual providing physical health services or behavioral health services to a patient. R9-10-706.B.1.b.i.ii.iii. An administrator shall ensure that the qualification, skills and knowledge required for each type of personnel member: Include: The specific skills and knowledge necessary for the personnel member to provide the expected behavioral health services.listed in the established job description, 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 behavioral health services.listed in the established job description, and 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 behavioral health services.listed in the established job description;

1. A review of E2’s (hired in 2021) personnel record revealed E2 was hired as the house manager. However, documentation of the verification of skills and knowledge was not available for review.

2. A review of E3’s (hired in 2022) personnel record revealed E3 was hired as a behavioral health paraprofessional. However, documentation of the verification of skills and knowledge was not available for review.

3. A review of E4’s (hired in 2021) personnel record revealed E4 was hired as a behavioral health technician (BHT). However, documentation of the verification of skills and knowledge was not available for review.

4. A review of E5’s (hired in 2022) personnel record revealed E2 was hired as a therapist/case manager. However, documentation of the verification of skills and knowledge was not available for review.

5. A review of E6’s (hired in 2020) personnel record revealed E6 was hired as the behavioral health professional. However, documentation of the verification of skills and knowledge was not available for review.

6. A review of E7’s (hired in 2021) personnel record revealed E7 was hired as a BHT. However, documentation of the verification of skills and knowledge was not available for review. 7. A review of E8’s (hired in 2021) personnel record revealed E8 was hired as the registered nurse. However, documentation of the verification of skills and knowledge was not available for review. 8. In a joint interview, E1 and E2 acknowledged E2’s, E3’s, E4’s, E5’s, E6’s, E7’s, and E8’s skills and knowledge were not verified and documented. Date permanent correction will be complete: 2023-06-14

Findings:

Rule: B. An administrator shall ensure that:

3. Sufficient personnel members are present on a behavioral health residential facility’s premises with the qualifications, experience, skills, and knowledge necessary to: a. Provide the services in the behavioral health residential facility’s scope of services, b. Meet the needs of a resident, and c. Ensure the health and safety of a resident.
Evidence: Based on observation, documentation review, record review, and interview, the administrator failed to ensure sufficient personnel members were present on a behavioral health residential facility’s premises with the qualifications, experience, skills, and knowledge necessary to meet the needs of a resident. The deficient practice posed a risk as a qualified personnel member was not present to meet a resident’s needs and ensure the health and safety, the Department was unable to determine substantial compliance as the documentation was not available during the inspection, and the documentation was not provided within two hours after a Department request.

Findings:

1. A review of E2’s (hired in 2021) personnel record revealed E2 was hired as the house manager. However, verification of skills and knowledge was not available for review.

2. A review of E3’s (hired in 2022) personnel record revealed E3 was hired as a behavioral health paraprofessional (BHPP). However, verification of skills and knowledge was not available for review.

3. A review of E4’s (hired in 2021) personnel record revealed E4 was hired as a behavioral health technician (BHT). However, verification of skills and knowledge was not available for review.

4. A review of E5’s (hired in 2022) personnel record revealed E2 was hired as a therapist/case manager. However, verification of skills and knowledge was not available for review.

5. A review of E6’s (hired in 2020) personnel record revealed E6 was hired as the behavioral health professional (BHP). However, verification of skills and knowledge was not available for review.

6. A review of E7’s (hired in 2021) personnel record revealed E7 was hired as a BHT. However, verification of skills and knowledge was not available for review. 7. A review of E8’s (hired in 2021) personnel record revealed E8 was hired as the registered nurse (RN). However, verification of skills and knowledge was not available for review. 8. A review of E2’s personnel record revealed E2 was hired as the house manager. However, documentation of education applicable to E2’s job duties was not available for review. 9. A review of E3’s personnel record revealed E3 was hired as a BHPP; caregiver. However, documentation of education applicable to E3’s job duties was not available for review. 10. A review of E4’s personnel record revealed E4 was hired as a BHT. However, documentation of education applicable to E4’s job duties was not available for review. 11. A review of E5’s personnel record revealed E5 was hired as a therapist/case manager. However, documentation of education applicable to E5’s job duties was not available for review. 12. A review of E6’s personnel record revealed E6 was hired as the behavioral health professional. However, documentation of education applicable to E6’s job duties was not available for review. 13. A review of E7’s personnel record revealed E7 was hired as a BHT. However, documentation of education applicable to E7’s job duties was not available for review. 14. In a joint interview, E1 and E2 acknowledged the findings. Date permanent correction will be complete: 2023-06-30

Rule: G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes:

3. Documentation of: b. The individual’s education and experience applicable to the individual’s job duties;
Evidence: Based on record review and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of the individual’s education applicable to the individual’s job duties, for six of seven personnel members sampled. The deficient practice posed a risk if a personnel member was unable to meet a resident’s needs, the Department was unable to determine substantial compliance as the documentation was not in the personnel records during the inspection, and the documentation was not provided within two hours after a Department request.

Findings:

1. A review of E2’s personnel record revealed E2 was hired as the house manager. However, documentation of education applicable to E2’s job duties was not available for review.

2. A review of E3’s personnel record revealed a job description for a behavioral health paraprofessional (BHPP). The job description stated “Qualifications and Education Requirements.Minimum of 21- years old; a High School Diploma or GED equivalency.” However, documentation of education was not available for review.

3. A review of E4’s personnel record revealed E4 was hired as a BHT. However, documentation of education applicable to E4’s job duties was not available for review.

4. A review of E5’s personnel record revealed E5 was hired as a therapist/case manager. However, documentation of education applicable to E5’s job duties was not available for review.

5. A review of E5’s personnel record revealed E5 was hired as a therapist/case manager. However, documentation of education applicable to E5’s job duties was not available for review.

6. A review of E6’s personnel record revealed E6 was hired as the behavioral health professional. However, documentation of education applicable to E6’s job duties was not available for review. 7. A review of E7’s personnel record revealed a job description for a behavioral health technician (BHT). The job description stated “Education, Experience and Preferred Qualifications.Minimum of High School diploma or GED.” However, documentation of education was not available for review. 8. In a joint interview, E1 and E2 acknowledged documentation of E2’s, E3’s, E4’s, E5’s, E6’s, and E7’s education applicable to their job duties was not available for review. Date permanent correction will be complete: 2023-07-11

Rule: G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes:

3. Documentation of: j.
Evidence: of freedom from infectious tuberculosis, if required for the individual according to subsection (F). Evidence Based on record review and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of evidence of freedom from infectious tuberculosis (TB), if required for the individual according to subsection (F), for one of nine personnel members sampled. The deficient practice posed a TB exposure risk to residents, the Department was unable to determine substantial compliance as the required documentation was not included in the personnel records during the inspection, and the documentation was not provided to the Department within two hours after a Department request.

Findings:

1. A review of E5s (hired in 2022) personnel record revealed documentation of a negative TB test was not available for review.

2. In a joint interview, E1 and E2 acknowledged current documentation of evidence of freedom from infectious TB for E5 was not available for review. Date permanent correction will be complete: 2023-07-15

Rule: K. An administrator shall ensure that:

3. There is a daily staffing schedule that: a. Indicates the date, scheduled work hours, and name of each employee assigned to work, including on-call personnel members; b. Includes documentation of the employees who work each calendar day and the hours worked by each employee; and c. Is maintained for at least 12 months after the last date on the documentation;
Evidence: Based on documentation review and interview, the administrator failed to ensure there was a daily staffing schedule indicating the date, scheduled work hours, and name of each employee assigned to work, including on-call personnel members; to include the behavioral health professional and the registered nurse, including documentation of the employees who worked each calendar day and the hours worked by each employee, and was maintained for at least 12 months after the last date on the documentation. The deficient practice posed a risk if there was no record to ensure shifts and tasks were covered, the Department was unable to determine substantial compliance as the documentation was not available during the inspection, and the documentation was not provided within two hours after a Department request.

Findings:

1. The Compliance Officer requested to review daily staffing schedules indicating the date, scheduled work hours, and name of each employee assigned to work, including on-call personnel members, including documentation of the employees who worked each calendar day and the hours worked by each employee.

2. A review of facility documentation revealed a daily staffing schedule dated February 27, 2023 to March 5, 2023. However, documentation maintained for at least 12 months after the last date on the documentation was not available for review.

3. A review of the daily staffing schedule revealed the daily staffing schedule did not include documentation of the employees who worked each calendar day and the hours worked by each employee, and did not include on-call personnel members to include the behavioral health professional and registered nurse.

4. In a joint interview interview, E1 and E2 acknowledged a daily staffing schedule which indicated the date, scheduled work hours, and name of each employee assigned to work, including on-call personnel members, included documentation of the employees who worked each calendar day and the hours worked by each employee, and was maintained for at least 12 months after the last date on the documentation was not available for review. Date permanent correction will be complete: 2023-09-28

Rule: A. An administrator shall ensure that: 9. Except as provided in subsection (A)(10), a behavioral health assessment for a resident is completed before treatment for the resident is initiated;
Evidence: Based on record review, documentation review, and interview, the administrator failed to ensure a behavioral health assessment was completed before treatment for the resident was initiated, for two of two current residents sampled. The deficient practice posed a risk as an analysis of the resident’s needs for behavioral health services to determine which services a health care institution would provide was not completed, the Department was unable to determine compliance as the documentation was not in the medical records during the inspection, and the documentation was not provided within two hours after a Department’s request.

Findings:

1. A review of R2’s (admitted in 2023) medical record revealed a behavioral health assessment for R2 was not available for review.

2. A review of electronic documentation provided by E1, revealed group and individual counseling notes dated in January 2023 and February 2023 for R2.

3. A review of R3’s (admitted in 2022) medical record revealed a behavioral health assessment for R3 was not available for review.

4. A review of electronic documentation provided by E1, revealed group and individual counseling notes dated in September 2022, October 2022, November 2022, December 2022, January 2023, and February 2023 for R3.

5. In a joint interview, E1 and E2 acknowledged R2’s and R3’s behavioral health assessments were not completed before treatment. Date permanent correction will be complete: 2023-08-26

Rule: A. An administrator shall ensure that: 13. Except as provided in subsection (E)(1)(d), a resident provides
Evidence: of freedom from infectious tuberculosis: a. Before or within seven calendar days after the resident’s admission, and b. As specified in R9-10-113. Evidence Based on record review and interview, the administrator failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident’s admission, for two of two current residents sampled and one of one discharged resident sampled. The deficient practice posed a TB exposure risk to residents, the Department was unable to determine substantial compliance as the documentation was not in the medical records during the inspection, and the documentation was not provided within two hours after a Department request.

Findings:

1. A review of R1’s (admitted in 2022) medical record revealed documentation of freedom from infectious TB was not available for review.

2. A review of R2’s (admitted in 2023) medical record revealed documentation of freedom from infectious TB was not available for review.

3. A review of R3’s (admitted in 2022) medical record revealed documentation of freedom from infectious TB was not available for review.

4. In a joint interview, E1 and E2 acknowledged R1, R2 and R3 did not provide evidence of freedom from infectious TB before or within seven calendar days after the resident’s admission. Date permanent correction will be complete: 2023-08-31

Rule: A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that:

2. Is completed: b. Before the resident receives physical health services or behavioral health services or within 48 hours after the assessment is completed;
Evidence: Based on record review, documentation review and interview, the administrator failed to ensure a treatment plan was developed for each resident and was completed before the resident received behavioral health services, for two of two current residents sampled. The deficient practice posed a risk as a treatment plan was not developed to articulate decisions and agreements before treatment was initiated, the Department was unable to determine substantial compliance as the documentation was not in the medical records during the inspection, and the documentation was not provided within two hours after a Department’s request.

Findings:

1. A review of R2’s (admitted in 2023) medical record revealed a treatment plan was not available for review.

2. A review of electronic documentation provided by E1, revealed group and individual counseling notes dated in January 2023 and February 2023 for R2.

3. A review of R3’s (admitted in 2022) medical record revealed a treatment plan was not available for review.

5. In a joint interview, E1 and E2 acknowledged R2’s and R3’s treatment plans were not completed before the resident received behavioral health services. Date permanent correction will be complete: 2023-08-31

Rule: A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that:

4. Includes: b. The physical health services or behavioral health services to be provided to the resident;
Evidence: Based on record review and interview, the administrator failed to ensure a treatment plan was developed for each resident to include the behavioral health services to be provided to the resident, for one of one discharged resident sampled. The deficient practice posed a risk a resident did not receive treatment to cure, improve, or palliate their behavioral health issue at the health care institution, the Department was unable to determine substantial compliance as the documentation was not in the medical record during the inspection, and the documentation was not provided within two hours after a Department request.

Findings:

1. A review of R1’s medical record revealed a treatment plan dated in February 2023. The treatment plan included various goals, objectives, and interventions. However, the treatment plan did not include the behavioral health services to be provided to R1.

2. In a joint interview, E1 and E2 acknowledged R1’s treatment plan did not include the behavioral health services to be provided to R1. Date permanent correction will be complete: 2023-08-31

Rule: A. An administrator shall ensure that:

1. The requirements in subsection (B) and the resident rights in subsection (E) are conspicuously posted on the premises;
Evidence: Based on observation and interview, the administrator failed to ensure the requirements in subsection (B) and the resident rights in subsection (E) were conspicuously posted on the premises. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not available during the inspection, and the documentation was not provided within two hours after a Department request.

Findings:

1. The Compliance Officer observed a facility posting titled “CLIENT COPY OF CLIENT RIGHTS.” The document stated “Arizona Statutes R9-20-203 Department of Behavioral Health Licensure.require that you be informed of your rights as a client.” However, the requirements in subsection (B) and the resident rights in subsection (E) were not conspicuously posted on the premises.

2. In a joint interview, E1 and E2 acknowledged the requirements and the rights from subsections (B) and (E) were not conspicuously posted on the premises. Date permanent correction will be complete: 2023-07-21

Rule: C. An administrator shall ensure that a resident’s medical record contains:

4. The date of admission and, if applicable, date of discharge;
Evidence: Based on record review and interview, the administrator failed to ensure a resident’s medical record contained the date of admission, for two of two current residents sampled and one of one discharged resident sampled and the date of discharge, for one of one discharged resident sampled. The deficient practice posed a risk the Department was unable to determine substantial compliance as the documentation was not in the medical records during the inspection, and the documentation was not provided within two hours after a Department request . Findings include:

1. A review of R1’s medical record revealed R1’s date of admission and discharge was not available for review.

2. A review of R2’s medical record revealed R2’s date of admission was not available for review.

3. A review of R3’s medical record revealed R3’s date of admission was not available for review.

4. In an interview, E1 reported R1’s date of admission was dated in July 2022 and R1’s date of discharge was dated in March 2023, R2’s date of admission was dated in January 2023, and R3’s date of admission was dated in November 2022.

5. In a joint interview, E1 and E2 acknowledged R1’s medical record did not include the date of admission or discharge and R2’s and R3’s medical records did not include the date of admission. Date permanent correction will be complete: 2023-11-14

Findings:

Rule: B. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that:

1. A disaster plan is developed, documented, maintained in a location accessible to personnel members and other employees, and, if necessary, implemented that includes: a. When, how, and where residents will be relocated;
Evidence: Based on documentation review and interview, the administrator failed to ensure a disaster plan include where residents would be relocated. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not available during the inspection and the documentation was not provided within two hours after a Department request. Findings:

1. A review of the facility’s electronic policies and procedures revealed a policy titled “Emergency and Safety Standards” (dated January 1, 2021). The policy stated “Arizona Children’s Group has entered into agreements or memorandums of understanding with a location designated as the evacuation site.Arizona Children’s Group has an agreement and a contract with relocation of residents in the event of an emergency evacuation.” However, the document did not include where residents would be relocated in the event of a disaster.

2. In a joint interview, E1 and E2 acknowledged the disaster plan did not include where residents would be relocated. Date permanent correction will be complete: 2023-11-14

Findings:

Rule: B. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that:

2. The disaster plan required in subsection (B)(1) is reviewed at least once every 12 months;
Evidence: Based on documentation review and interview, the administrator failed to ensure the disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees, the Department was unable to determine substantial compliance as the documentation was not available during the inspection, and the documentation was not provided within two hours after a Department request.

Findings:

1. A review of Department documentation revealed the facility’s perpetual license was effective on November 29, 2019.

2. A review of the facility’s electronic policies and procedures revealed a document titled “DISASTER PLAN REVIEW- AT LEAST ONCE EVERY 12 MONTHS” (dated January 4, 2021). However, documentation to indicate the disaster plan was reviewed at least once every 12 months was not available for review.

3. In a joint interview, E1 and E2 acknowledged the facility’s disaster plan had not been reviewed at least once every 12 months. Plan of Correction Name, title and/or Position of the Person Responsible Temporary Solution Date temporary correction was implemented Date permanent correction will be complete 2023-11-18 Permanent Solution Monitoring

Rule: B. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that:

4. A disaster drill for employees is conducted on each shift at least once every three months and documented;
Evidence: Based on documentation review and interview, the administrator failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan, the Department was unable to determine substantial compliance as the documentation was not available during the inspection, and the documentation was not provided within two hours after a Department request.

Findings:

1. A review of Department documentation revealed the facility’s perpetual license was effective on November 29, 2019.

2. A review of facility documentation revealed a daily staffing schedule. The daily staffing schedule revealed the facility maintained the following shifts: -8:00 AM to 3:00 PM; -8:00 AM to 4:00 PM; -2:00 PM to 9:00 PM; -2:00 PM to 10:00 PM; -2:00 PM to 11:00 PM; -3:00 PM to 9:00 PM; -3:00 PM to 11:00 PM; -4:00 PM to 9:00 PM; -4:00 PM to 10:00 PM; -4:00 PM to 11:00 PM; -10:00 PM to 8:00 AM; and -11:00 PM to 8:00 AM.

3. A review of facility documentation revealed disaster drills for employees conducted on each shift at least once every three months was not available for review.

4. In a joint interview, E1 and E2 acknowledged disaster drills for employees were not conducted and documented on each shift at least once every three months and documented. Date permanent correction will be complete: 2023-11-14

Rule: B. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that:

5. An evacuation drill for employees and residents on the premises is conducted at least once every six months on each shift;
Evidence: Based on documentation review and interview, the administrator failed to ensure an evacuation drill for employees and residents on the premises was conducted at least once every six months on each shift. The deficient practice posed a risk if employees were unable to implement a disaster plan, the Department was unable to determine substantial compliance as the documentation was not available during the inspection, and the documentation was not provided within two hours after a Department request. Findings include:

1. A review of facility documentation revealed a daily staffing schedule. The daily staffing schedule revealed the facility maintained the following shifts: -8:00 AM to 3:00 PM; -8:00 AM to 4:00 PM; -2:00 PM to 9:00 PM; -2:00 PM to 10:00 PM; -2:00 PM to 11:00 PM; -3:00 PM to 9:00 PM; -3:00 PM to 11:00 PM; -4:00 PM to 9:00 PM; -4:00 PM to 10:00 PM; -4:00 PM to 11:00 PM; -10:00 PM to 8:00 AM; and -11:00 PM to 8:00 AM.

2. A review of facility documentation revealed evacuation drills for employees and residents on the premises were conducted on the following dates and shift: -November 15, 2022 at 8:46 PM; and -August 5, 2022 at 11 PM. However, evacuation drills conducted at least once every six months on each shift were not available for review.

3. In a joint interview, E1 and E2 acknowledged evacuation drills for employees and residents were not conducted on each shift at least once every six months on each shift. Date permanent correction will be complete: 2023-06-14

Findings:

Rule: A. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that:

1. The premises and equipment are: c. Free from a condition or situation that may cause a resident or other individual to suffer physical injury;
Evidence: Based on observation and interview, the administrator failed to ensure the facility was free from a condition or situation to cause a resident or other individual to suffer physical injury. The deficient practice posed a risk as a ligature point was identified in the behavioral health residential facility.

Findings:

1. The Compliance Officer observed, in a shared bedroom, a sliding barn door leading into the shared bathroom. The Compliance Officer observed the track for the sliding barn door was bolted into the wall, with a space between the track and wall. However, this space created a ligature point.

2. A review of R1’s medical record revealed a document titled “Emotional Concerns.” The document included statements with boxes next to the statements. The following box was checked “I have had thoughts of suicide or harming myself.”

3. A review of R2’s medical record revealed a document titled “Emotional Concerns.” The document included statements with boxes next to the statements. The following box was checked “I have had thoughts of suicide or harming myself.I have cut myself or mutilated part of my body.”

4. A review of R3’s medical record revealed a document titled “Emotional Concerns.” The document included statements with boxes next to the statements. The following box was checked “I have had thoughts of suicide or harming myself.I have cut myself or mutilated part of my body.”

5. In a joint interview, E1 and E2 acknowledged the facility was not free from a condition or situation that could cause a resident or other individual to suffer physical injury. Date permanent correction will be complete: 2023-07-13

Rule: A. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that:

2. A pest control program that complies with A.A.C. R3-8-20l(C)(4) is implemented and documented;
Evidence: Based on documentation review and interview, the administrator failed to ensure a pest control program documented. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not available during the inspection, and the documentation was not provided within two hours after a Department request.

Findings:

1. The Compliance Officers requested to review the facility’s pest control program. However, documentation of a current pest control program was not provided for review.

2. In an interview, E1 reported BH5927 does not have a pest control program.

3. In a joint interview, E1 and E2 acknowledged a pest control program was not available for review. Date permanent correction will be complete: 2023-05-21

Rule: B. An administrator shall ensure that: 8. A resident bedroom complies with the following: k. Has a clothing rod or hook in the bedroom designed to minimize the opportunity for a resident to cause self-injury.
Evidence: Based on observation and interview, the administrator failed to ensure a resident bedroom had a clothing rod in the bedroom designed to minimize the opportunity for a resident to cause self-injury. The deficient practice posed a risk to the physical health and safety of residents.

Findings:

1. The Compliance Officer observed clothing rods in R1’s, R2’s, R3’s, and R4’s bedrooms closets. However, the rods did not give way when a Compliance Officer applied downward pressure.

5. In a joint interview, E1 and E2 acknowledged the rods were a health and safety risk and did not give way when the Compliance Officers applied downward pressure. Date permanent correction will be complete: 2023-08-03

Compliance (Annual) on 2/20/2025

Rule: A.R.S. § 36-424.C. Inspections; suspension or revocation of license; report to board of examiners of nursing care institution administrators and assisted living facility managers C. On a determination by the director that there is reasonable cause to believe a health care institution is not adhering to the licensing requirements of this chapter, the director and any duly designated employee or agent of the director, including county health representatives and county or municipal fire inspectors, consistent with standard medical practices, may enter on and into the premises of any health care institution that is licensed or required to be licensed pursuant to this chapter at any reasonable time for the purpose of determining the state of compliance with this chapter, the rules adopted pursuant to this chapter and local fire ordinances or rules. Any application for licensure under this chapter constitutes permission for and complete acquiescence in any entry or inspection of the premises during the pendency of the application and, if licensed, during the term of the license. If an inspection reveals that the health care institution is not adhering to the licensing requirements established pursuant to this chapter, the director may take action authorized by this chapter. Any health care institution, including an accredited hospital, whose license has been suspended or revoked in accordance with this section is subject to inspection on application for relicensure or reinstatement of license.
Evidence: Based on documentation review, observation, and interview, the licensee failed to provide complete acquiescence in any entry or inspection of the premises during the term of the license. The deficient practice posed a risk as such action is deemed as a reasonable cause to believe a substantial violation under A.R.S. § 36-427(B) exists.

Findings:

1. A review of Department documentation revealed the facility’s perpetual license was effective on November 29, 2019.

2. The Compliance Officer arrived at the facility at 10:45 AM to conduct a compliance inspection. The Compliance Officer rang the door bell and knocked at the door. However, no one answered the door.

3.The Compliance Officer observed what appeared to be a for sale sign posted in the front yard.

4. In a telephonic interview, conducted at 10:51 AM, E1 reported the facility does not have any current residents and reported no one was on premises. E1 reported E1 could not meet the Compliance Officer as E1 was at an appointment.

5. The Compliance Officer called E1 again and left voicemail 10:58 AM and sent a text message at 11:10 AM.

6. The Compliance Officer did not receive a response from E1 and left the facility at 11:57 AM.

Complaint;Compliance (Annual) on 1/11/2024

Rule: 36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition A. Each health care institution shall develop and administer a training program for all staff regarding fall prevention and fall recovery. The training program shall include initial training and continued competency training in fall prevention and fall recovery. A health care institution may use information and training materials from the department’s Arizona falls prevention coalition in developing the training program.
Evidence: Based on documentation review, record review, and interview, the health care institution failed to develop a training program for all staff regarding fall prevention and fall recovery to include initial training and continued competency training in fall prevention and fall recovery. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not developed and implemented.

Findings:

1. A review of the facility’s policies and procedures revealed a policy titled “Fall Prevention and Recovery Training for Caregivers” (date unavailable). However, the initial training and continued competency training requirement for all staff was not included in the policy.

2. In a joint interview, E1 and E2 acknowledged the policy did not include the initial training and continued training for all staff. This is a repeat deficiency from the on-site compliance and complaint inspection conducted on March 3, 2023. Date permanent correction will be complete 2024-01-23 Monitoring

Rule: B. An administrator:

3. Except as provided in subsection (A)(6), designates, in writing, an individual who is present on the behavioral health residential facility’s premises and accountable for the behavioral health residential facility when the administrator is not present on the behavioral health residential facility’s premises.
Evidence: Based on observation, record review, documentation review, and interview, the administrator failed to designate, in writing, an individual who was present on the behavioral health residential facility’s premises and accountable for the behavioral health residential facility when the administrator was not present on the behavioral health residential facility’s premises. The deficient practice posed a risk as E2 and E10 were not present on the premises and accountable when E1 was not present on the premises. Findings include:

1. The Compliance Officer observed E3 working, alone, on the premises when the Compliance Officer arrived at approximately 11:20 AM.

2. A review of E3’s (hired in 2023) personnel record revealed E3 was hired as a behavioral health technician (BHT/Peer Support). However, documentation designating E3 to be present on the behavioral health residential facility’s premises and accountable for the behavioral health facility when the administrator was not present was not available for review.

3. The Compliance Officer observed E1 and E2 arrive on the premises at approximately 11:58 AM.

4. A review of the facility’s policies and procedures revealed a policy titled “Administrator” (dated November 27, 2021). The policy stated “The Administrator may designates [sic] in writing, an individual who is present on the Arizona Children’s Group Premises and accountable for the facility when the Administrator is not present and on-site.During the absence of the Administrator, a qualified designee will be the designated relief person who will assume the necessary Administrator responsibilities for the day-to-day operations of Arizona Children’s Group in the interim.I [E10], accept the responsibility of Alternative Administrator for the agency on Monday-Friday, 8 a.m. to 5 p.m., in the absence of the above Administrator.I [E2], accept the responsibility of the secondary Alternative Administrator for the agency on Monday-Friday, 8 a.m. to 5 p.m., in the absence of the above primary Alternate Administrator.” The document was signed and dated in 2023, by E1, E2, and E10.

5. In a joint interview, E1 and E2 acknowledged E2 and E10 were not present on the behavioral health residential facility’s premises and accountable for the behavioral health residential facility when E1 was not present on the behavioral health residential facility’s premises. This is a repeat deficiency from the on-site compliance and complaint inspection conducted on March 3, 2023. Date permanent correction will be complete: 2024-01-15

Findings:

Rule: C. An administrator shall ensure that:

Findings:

1. A review of Department documentation revealed the facility’s perpetual license was effective on November 29, 2019.

2. A review of the facility’s policies and procedures (dated November 27, 2021) revealed policies and procedures to include qualifications, including skills and knowledge were not available for review.

3. In a joint interview, E1 and E2 acknowledged policies and procedures were not established and documented to cover required skills and knowledge for personnel members, employees, volunteers, and students. This is a repeat deficiency from the on-site compliance and complaint inspection conducted on March 3, 2023. Date permanent correction will be complete: 2024-01-17

Rule: C. An administrator shall ensure that:

Findings:

1. The Compliance Officer requested complete personnel records (per R9-10-706.G.1-3) for E1, E3, E4, E5, E6, E7, and E8 at 12:00 PM.

2. A review of E3’s, E4’s, and E6’s personnel records revealed documentation of clinical oversight for the month of December 2023 was not available for review.

3. A review of documentation provided by E1, at approximately 6:00 PM, reveal clinical oversight for E3, E4, and E6.

4. A review of E7’s (hired in 2023) personnel record revealed E7 was hired as the registered nurse. However, documentation of E7’s completed orientation was not available for review.

5. A review of E8’s (hired in 2023) personnel record revealed E8 was hired as the behavioral health professional. However, documentation of E8’s completed orientation was not available for review.

6. In a joint interview, E1 and E2 acknowledged the requested documentation was not provided within two hours after a Department request. This is a repeat deficiency from the on-site compliance and complaint inspection conducted on March 3, 2023. Date permanent correction will be complete: 2024-02-12

Rule: E. An administrator shall ensure that:

Findings: R9-10-101.153. “Orientation” means the initial instruction and information provided to an individual before the individual starts work or volunteer services in a health care institution.

1. A review of the facility’s policies and procedures revealed a policy titled “Staff Qualifications, Training, and Responsibilities” (dated January 1, 2021). The policy stated “.When a community residential service is delivered.a direct care staff shall be present who has completed the following required training.Orientation to the specific needs of clients living in the community residential setting.”

2. A review of E7’s (hired in 2023) personnel record revealed E7 was hired as the registered nurse. However, documentation of E7’s completed orientation was not available for review.

3. A review of E8’s (hired in 2023) personnel record revealed E8 was hired as the behavioral health professional. However, documentation of E8’s completed orientation was not available for review.

4. In a joint interview, E1 and E2 acknowledged E7’s and E8’s orientation had not been completed prior to providing behavioral health services or physical health services. Date permanent correction will be complete: 2024-01-23

Findings:

1. A review of R2’s (admitted in 2023) medical record revealed documentation a TB test had been administered (dated in October 2023). However, documentation of the TB test result and freedom from infectious TB was not available for review.

2. In a joint interview, E1 and E2 acknowledged R2 did not provide evidence of freedom from infectious TB before or within seven calendar days after R2’s admission. This is a repeat deficiency from the on-site compliance and complaint investigation conducted on March 3, 2023. Date permanent correction will be complete: 2024-02-10

Rule: A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that:

4. Includes: b. The physical health services or behavioral health services to be provided to the resident;
Evidence: Based on record review and interview, the administrator failed to ensure a treatment plan was developed for each resident to include the number of hours of counseling to be provided to the resident per R9-10-716(B)(2), for two of two current residents sampled and one of four discharged residents sampled. The deficient practice posed a risk if a resident did not receive treatment to cure, improve, or palliate their behavioral health issue at the health care institution.

Findings:

1. A review of R1’s medical record revealed a treatment plan (dated in December 2023). The treatment plan did include the frequency of counseling to be provided. However, the treatment plan did not include the number of hours of counseling to be provided to R1.

2. A review of R2’s medical record revealed a treatment plan (dated in December 2023). The treatment plan did include the frequency of counseling to be provided. However, the treatment plan did not include the number of hours of counseling to be provided to R2.

3. A review of R4’s medical record revealed a treatment plan (dated in September 2023). The treatment plan did include the frequency of counseling to be provided. However, the treatment plan did not include the number of hours of counseling to be provided to R4.

4. In a joint interview, E1 and E2 acknowledged R1’s, R2’s, and R4’s treatment plans did not include the number of hours of counseling to be provided to R1, R2 and R4. Date permanent correction will be complete: 2024-01-22

Rule: A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that:

4. Includes: c. The signature of the resident or the resident’s representative, and date signed, or documentation of the refusal to sign;
Evidence: Based on record review and interview, the administrator failed to ensure a treatment plan was developed for each resident to include the signature of the resident’s representative, and the date signed, or documentation of the refusal to sign, for two of two current residents sampled. The deficient practice posed a risk if the treatment plan was not developed to articulate decisions and agreements. Findings include:

1. A review of R1’s medical record revealed a treatment plan (dated in December 2023) developed by E8. However, the treatment plan did not include the signature of the resident’s representative, and the date signed, or documentation of the refusal to sign.

2. A review of R2’s medical record revealed a treatment plan (dated in December 2023) developed by E8. However, the treatment plan did not include the signature of the resident’s representative, and the date signed, or documentation of the refusal to sign.

3. In a joint interview, E1 and E2 acknowledged R1’s and R2’s treatment plans did not include the signature of the resident’s representative, and date signed, or documentation of the refusal to sign. Date permanent correction will be complete: 2024-01-22

Findings:

Rule: A. An administrator shall ensure that:

2. At the time of admission, a resident or the resident’s representative receives a written copy of the requirements in subsection (B) and the resident rights in subsection (E); and
Evidence: Based on record review and interview, the administrator failed to ensure at the time of admission, a resident or the resident’s representative received a written copy of the requirements in subsection (B) and the resident rights in subsection (E), for two of two current residents sampled. The deficient practice posed a risk as individuals were not informed of the resident requirements and rights.

Findings:

1. A review of R1’s and R2’s medical records revealed documented evidence of R1 and R2 receiving a written copy of the requirements in subsection (B) and the resident rights in subsection (E) were not available for review.

2. In a joint interview, E1 and E2 acknowledged the two residents or resident’s representatives did not receive a written copy of the requirements in subsection (B) and the resident rights in subsection (E). Date permanent correction will be complete: 2024-01-13

ARTEMIS ADOLESCENT HEALING CENTER
16330 North Forecastle Avenue, Tucson, AZ 85739

Complaint;Initial Monitoring on 6/26/2025

Rule: R9-10-703.A.2.a-b. Administration A. A governing authority shall:

2. Establish, in writing: a. A behavioral health residential facility’s scope of services, and b. Qualifications for an administrator;
Evidence: Based on documentation review and interview, the governing authority failed to establish in writing the behavioral health residential facility’s scope of services. The deficient practice posed a risk as the scope of services did not include the correct age group.

Findings:

1. A review of Department documentation revealed a Behavioral Health Residential Facility License (BH10722) was issued on April 29, 2025.

2. A review of facility documentation revealed a policy titled “RES 00001 – Residential Services” (dated on March 1, 2025). The procedure stated “Catalina Behavioral Health. Description of the Residential Program. Artemis Healing Center is a substance abuse treatment residential treatment center. Services are provided to adults eighteen years of age and up.”

3. A review of R2’s, R3’s, and R4’s medical records revealed each resident was under eighteen (18) years of age.

4. In an exit interview, the findings were reviewed with E1, and no further documentation or comments were provided.

Rule: R9-10-707.A.6. Admission; Assessment A. An administrator shall ensure that:

6. Except as provided in subsection (E)(1)(a), a medical practitioner performs a medical history and physical examination or a registered nurse performs a nursing assessment on a resident within 30 calendar days before admission or within 72 hours after admission and documents the medical history and physical examination or
Evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a medical practitioner performed a medical history and physical examination (H&P) or a registered nurse (RN) performed a nursing assessment on a resident within 30 calendar days before admission or within 72 hours after admission and documented the medical history and physical examination or nursing assessment in the resident’s medical record within 72 hours after admission; nursing assessment in the resident’s medical record within 72 hours after admission, for one of five resident records sampled. The deficient practice posed a risk as this information was required for the development and implementation of a treatment plan, per R9- 10-708.A.1.

Findings:

1. A review of facility documentation revealed a policy titled “Clin 00004 – Assessment” (dated on March 1, 2025). The procedure stated “A medical history and physical or nursing assessment will be conducted, that will include.

3. A medical history and physical or nursing assessment will be conducted within 30 calendar days before admission, or within 72 hours after admission.

4. The medical history and physical or nursing assessment will be documented in the resident’s medical record within 72 hours after admission.”

2. A review of R2’s medical record (admitted in June 2025) revealed no documentation which indicated a medical practitioner performed an H&P or an RN performed a nursing assessment.

3. In an exit interview, the findings were reviewed with E1, and no further documentation or comments were provided.

Rule: R9-10-707.A.7. Admission; Assessment A. An administrator shall ensure that: 7. If a medical practitioner performs a medical history and physical examination or a nurse performs a nursing assessment on a resident before admission, the medical practitioner enters an interval note or the nurse enters a progress note in the resident’s medical record within seven calendar days after admission;
Evidence: Based on documentation review, record review, and interview, the administrator failed to ensure when a medical practitioner performed a medical history and physical examination (H&P) on a resident before admission, the medical practitioner entered an interval note in the resident’s medical record within seven calendar days after admission, for three of five resident records sampled. The deficient practice posed a risk of not meeting a resident’s needs if no medical history and physical examination was completed to assess a resident’s needs prior to treatment.

Findings:

3. A medical history and physical or nursing assessment will be conducted within 30 calendar days before admission, or within 72 hours after admission.

4. The medical history and physical or nursing assessment will be documented in the resident’s medical record within 72 hours after admission.”

2. A review of R3’s medical record (admitted in June 2025) revealed an H&P performed in May 2025; however, there was no evidence of a documented progress note from a medical practitioner within seven (7) calendar days after admission.

3. A review of R4’s medical record (admitted in June 2025) revealed an H&P performed in May 2025; however, there was no evidence of a documented progress note from a medical practitioner within seven (7) calendar days after admission..

4. In an exit interview, the findings were reviewed with E1, and no further documentation or comments were provided.

Rule: R9-10-708.A.5. Treatment Plan A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that:

5. If the treatment plan was completed by a behavioral health technician, is reviewed and signed by a behavioral health professional within 24 hours after the completion of the treatment plan to ensure that the treatment plan is complete and accurate and meets the resident’s treatment needs; and
Evidence: Based on documentation review, record review, and interview, the administrator failed to ensure when a treatment plan was completed by a behavioral health technician (BHT), within 24 hours a behavioral health professional (BHP) reviewed and signed the treatment plan to ensure it was complete and accurate and met the residents’ treatment needs, for two of five resident records sampled. The deficient practice posed a risk as a description of the resident’s behavioral health services to be provided was not reviewed within 24 hours to ensure the treatment plan was complete and accurate.

Findings:

1. A review of facility documentation revealed a policy titled “Clin 00012 – Clinical Oversight” (dated on March 1, 2025). The procedure stated “Behavioral health technicians/care coordinators are trained to provide the following clinical services: Treatment planning. Behavioral health assessments. Some group counseling. If a treatment plan or behavioral health assessment is performed by a behavioral health tech/care coordinator, the BHP/supervisor that is licensed to practice independently shall review and approve the treatment plan or behavioral health assessment within 24 hours.”

2. A review of R2’s medical record (admitted in May 2025) revealed a treatment plan, dated in May 2025, was completed by a BHT. However, the treatment plan was not reviewed and signed by a BHP until 98 hours after.

3. A review of R3’s medical record (admitted in June 2025) revealed a treatment plan, dated in June 2025, was completed by O1, a BHT. However, the treatment plan was not reviewed and signed by a BHP until 73 hours after.

4. In an exit interview, the findings were reviewed with E1, and no further documentation or comments were provided.

Rule: R9-10-721.A.1.a. Environmental Standards A. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that:

1. The premises and equipment are: a. Maintained in a condition that allows the
Evidence: Based on documentation review, observation, and interview, the administrator failed to ensure the premises and equipment were maintained in a condition which allowed the premises and equipment to be used for the original purpose of the premises and equipment. The deficient practice posed a risk of the facility being able to provide a safe, premises and equipment to be used for the original purpose of the premises and equipment; functional environment, and the Department was unable to ensure the facility’s compliance.

Findings:

1. The Compliance Officer observed in the facility’s kitchen and living room, where large pieces of plywood had been installed to cover approximately half of the broken windows.

2. In an interview, E1 reported a resident had exhibited sudden, intense, and out-of-control behavior at the facility, which resulted in broken windows.

3. In an interview, E1 reported the replacement windows required custom fabrication by an external company, with an estimated turnaround time of five to seven weeks. E1 reported the facility had placed the order two weeks prior to June 26, 2025.

4. In an exit interview, the findings were reviewed with E1, and no further documentation or comments were provided.

Compliance (Initial) on 4/23/2025

No violations noted.

Compliance (Initial) on 4/23/2025

No violations noted.

AVERY’S HOUSE, LLC
2416 North 113th Street, Apache Junction, AZ 85120

Complaint on 9/5/2024

Rule: G. An administrator shall provide written notification to the Department of a resident’s:

2. Self-injury, within two working days after the resident inflicts a self-injury or has an accident that requires immediate intervention by an emergency medical services provider.
Evidence: Based on record review, documentation review and interview, the administrator failed to provide written notification to the Department of a resident’s self-injury, within two working days after the resident inflicted a self-injury requiring immediate intervention by an emergency medical services provider. The deficient practice posed a risk as the Department was unable to determine if there was an immediate health and safety risk to other residents admitted into the facility.

Findings:

1. A review of R1′ s medical record revealed an incident report of a medical overdose by R1 on September 1, 2024. The report stated “At med pass, [R1] was given [R1] seroquel and [R1] took the bottle, emptied it into [R1] mouth, and swallowed 13 or 14 tablets.” The report indicated E4 contacted 911 and poison control, and R1 was transported and admitted to the hospital.

2. A review of Department documentation revealed documentation to demonstrate BH7513 provided written notification to the Department of R1’s self-injury was not available for review.

3. In an interview, E1 reported R1 was receiving assistance in the self-administration of medication during the aforementioned incident by E4. E1 reported E4 opened the medication bottle of Seroquel 100 mg and handed it to R1 to complete the assistance in the self-administration of medication. E1 reported R1 reported the overdose was a suicide attempt. Date permanent correction will be complete: 2024-11-22

Rule: A. An administrator shall ensure that: 7. A resident does not: a. Use or have access to any materials, furnishings, or equipment or participate in any activity or treatment that may present a threat to the resident’s health or safety based on the resident’s documented diagnosis, treatment needs, developmental levels, social skills, verbal skills, or personal history; or
Evidence: Based on record review and interview, the administrator failed to ensure a resident did not have access to any materials, furnishings, or equipment or participate in any activity or treatment to present a threat to the resident’s health or safety based on the resident’s personal history. The deficient practice posed a risk as R1 had access to administer medication while admitted into a behavioral health residential facility in contradiction with their personal history.

Findings:

1. A review of R1’s medical record revealed an incident report of a medical overdose by R1 on September 1, 2024. The report stated “At med pass, [R1] was given [R1] seroquel and [R1] took the bottle, emptied it into [R1] mouth, and swallowed 13 or 14 tablets.” The report indicated E4 contacted 911 and poison control, and R1 was transported and admitted to the hospital.

2. A review of R1’s medical record revealed a medication administration record (MAR) for September 2024. The MAR indicated E5 provided assistance in the self- administration of medication for Seroquel 100 mg on September 1, 2024.

3. A review of R1’s medical record revealed a behavioral health assessment dated in 2024. The assessment stated R1 is diagnosed with “bipolar disorder”, had “3-4 attempts” of suicide, and had “tried to overdose with Benadryl.”

4. In an interview, E1 reported R1 was receiving assistance in the self-administration of medication during the aforementioned incident by E4. E1 reported E4 opened the medication bottle of Seroquel 100 mg and handed it to R1 to complete the assistance in the self-administration of medication. Date permanent correction will be complete: 2024-11-22

Compliance (Annual) on 8/8/2023

No violations noted.

Complaint on 8/31/2023

Rule: K. An administrator shall: 8. Maintain a written log of unauthorized absences for at least 12 months after the date of a resident’s absence that includes the: a. Name of a resident absent without authorization, b. Name of the individual to whom the report required in subsection (K)(7) was submitted, and c. Date of the report; and
Evidence: Based on documentation review and interview, the administrator failed to maintain a log of unauthorized absences that included the name of a resident absent without authorization, the name of the individual to whom the report required in subsection (K)(7) was submitted, and the date of the report.

Findings:

1. A review of facility incident reports revealed three resident elopements on July 18, 2023, and two resident elopements on July 23, 2023. A review of facility documentation revealed no log of unauthorized absences was available for review.

2. In documentation review, a facility policy, titled, “Discharge Against Medical Advice (AMA) and (AWOL), page 81, documented, “.An AWOL log will be maintained by the Clinical Director of all clients leaving AWOL, this log shall be reviewed as a part of the quality management program. The log must contain a list of all unauthorized absences for at least 12 months after the date of a clients absence that includes the residences name, to whom the report was submitted, the date of the report the evaluation and any action that was taken because of the unauthorized absence.”

3. During an interview, E1, E2, and E3 reported R1, R2, R3, and R4 left the facility without authorization in July 2023. E1 reported a log of unauthorized absences had not been maintained by the administrator. Date permanent correction will be complete: 2023-10-28

Rule: B. An administrator shall ensure that:

Findings:

1. In record review, the personnel record for E6 (hired November 7, 2022, as a Behavioral Health Technician) included documentation of the verification of skills and knowledge dated March 24, 2023.

2. During an interview, E1 reported E6 was hired on November 7, 2022; however, the documentation of E4’s skills and knowledge was not completed until March 24, 2023, and before E4 provided behavioral health services, as required. Date permanent correction will be complete: 2023-10-28

Rule: E. An administrator shall ensure that:

2. A personnel member completes orientation before providing behavioral health services or physical health services;
Evidence: Based on record review, and interview, for one of two personnel records reviewed, the administrator failed to ensure a personnel member completed orientation before providing behavioral health services. The deficient practice posed a risk if an employee was not provided orientation before providing behavioral health services to residents.

Findings: R9-10-101(155) “Orientation” means the initial instruction and information provided to an individual before the individual starts work or volunteer services in a health care institution.

1. In record review, the personnel record for E6 (hired November 7, 2022, as a Behavioral Health Technician), did not include documentation of orientation.

2. During an interview, the personnel record was reviewed with E1, who acknowledged E6’s personnel record did not include documentation of completed orientation before providing behavioral and/or physical health services. Date permanent correction will be complete: 2023-10-28

Rule: G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes:

Findings: A.R.S. \’a7 36-425.03(E) states “Children’s behavioral health program personnel shall certify on forms that are provided by the department and notarized that they are not awaiting trial on or have never been convicted of or admitted in open court or pursuant to a plea agreement to committing any of the offenses listed in section 41-1758.03, subsection B or C in this state or similar offenses in another state or jurisdiction.”

1. In record review, E6’s personnel record (hired November 7 2022) as a behavioral health technician (BHT) included a valid fingerprint clearance card; however, documentation of compliance with A.R.S. \’a7 36-425.03(E) was not provided for review.

2. In record review, E7’s personnel record (hired September 2, 2022) as a behavioral health technician (BHT) included a valid fingerprint clearance card; however, documentation of compliance with A.R.S. \’a7 36-425.03(E) was not provided for review.

3. During an interview, E1 acknowledged the personnel records did not include the required documentation of compliance with A.R.S. \’a7 36-425.03(E). Date permanent correction will be complete: 2023-10-28

Complaint on 8/30/2024

No violations noted.

Complaint on 7/10/2024

No violations noted.

Complaint on 2/12/2025

Rule: R9-10-703.C.1.f. Administration C. An administrator shall ensure that:

1. Policies and procedures are established, documented, and implemented to protect the health and safety of a resident that: f. Cover implementation of the requirements in A.R.S. §§ 36-411, 36-411.01, and 36-425.03, as applicable;
Evidence: Based on observation, documentation review and record review, the administrator failed to ensure policies and procedures were implemented to protect the health and safety of a resident that cover implementation of the requirements in A.R.S. §§ 36-425.03.

Findings:

1. The Compliance Officer observed E4 working on-site.

2. A review of the facility’s policies and procedures revealed a policy titled “Job Descriptions“ dated November 1, 2021. The policy stated “Position: Behavioral Health Technician…Minimum qualifications…Current and valid Arizona Fingerprint Card.”

3. A review of E4’s (hired as a behavioral health technician) personnel record revealed a print out from the Department of Public Safety’s website. The document included a fingerprint clearance card application number for E4, however, the document stated “Status In process”.

4. A review of the AZDPS Fingerprint Clearance Status website revealed E4’s fingerprint clearance card application was received by AZDPS on September 10, 2024, however the status was “In Process”.

5. In an interview, E1 reported to not be sure of the current status of E4’s fingerprint clearance card.

6. In an exit interview, the findings were reviewed with E1, E2, and E3, and further documentation or comment was not provided. Plan of Correction Name, title and/or Position of the Person Responsible Kaleigh Telles, President Date temporary correction was implemented Date permanent correction will be complete 2025-03-14 Temporary Solution Attached is a record of a processing error for the fingerprint application for E4 tracking the updates. Permanent Solution Fingerprint clearance card for E4 was successfully processed after the error with AZDPS was identified and as of 02/21/2025 the status is “valid” (see attached). Job description qualifications section will be updated to include verbiage covering new hires who have applied and the application is in process in accordance with ADHS standards. Monitoring We will continue to monitor processing applications and confirm clearance is approved timely. We will review all job descriptions to ensure qualifications are in line with current practices and ADHS standards.

AVERY’S HOUSE
11057 North Pinto Drive, Fountain Hills, AZ 85268

Complaint on 9/5/2024

No violations noted.

Complaint on 9/30/2022

Rule: C. An administrator shall ensure that:

1. Policies and procedures are established, documented, and implemented to protect the health and safety of a resident that: n. Cover a quality management program, including incident reports and supporting documentation;
Evidence: Based on documentation review, record review, and interview, for four of seven residents reviewed, the administrator failed to implement the facility’s policy and procedures for incident reporting, which posed a risk if the facility did not have a documented report of incidents affecting resident health and safety.

Findings:

1. In documentation review, a facility policy titled, “Incident reporting,” approved July 2021, page 117, documented, “To ensure all potential risk incidents are assessed and interventions implemented based on assurance of safety for clients, staff, and visitors. Incident reports will be completed for any incident that provides a real or perceived risk to the organization, clients, staff, or visitors. Reports will be utilized in improving safety and security of the facility.. A. Incident reports will be completed for all incidents within 24 hours of the incident and provided to the Director for review. B. Examples of incidents to report include a. Injuries to clients, staff, or visitors, b. Damage to . staff, client, or visitor property c. Security incidents d. Emergency occurrences E. Violence or threat of violence f. Self-harm. An incident report will include; . Names. Place of incident . Nature of . incident. Steps taken during the incident. Follow up needed. follow up completed. Incident reports will be utilized to assist in the organizations environment of care and safety plans. Director will be responsible for completing a monthly review of IR’s received and evaluating situations, responses, and any necessary measures.”

2. In an interview, R2 reported being sent to the emergency room (ER) on July 4, 2022, after experiencing post acute withdrawal symptoms. R3 reported being sent by ambulance to the hospital for treatment after having a seizure. R4 reported having falls at the facility and was sent to the ER for heat exhaustion following equine therapy. R5 reported being sent to the hospital for treatment, on June 29, 2022, after having heart palpitations.

3. In an interview, the findings were reviewed with E1, E2, and E6 who reported being unable to locate the incident reports completed following the incidents at the facility. E2 reported R2, R3, and R5 were sent to the hospital for treatment, and reported R4 had a fall with ankle swelling after tripping when exiting the facility van. E1, E2 and E6 were not aware R4 was sent to the ER for heat exhaustion. Date permanent correction will be complete: 2022-11-30

Other on 5/28/2024

No violations noted.

Compliance (Annual) on 4/17/2023

No violations noted.

Change of Service on 12/5/2023 – 12/20/2023

No violations noted.

Arizona Community Protection And Treatment Center
2500 East Van Buren Street, Phoenix, AZ 85008

Complaint on 3/26/2024 – 4/4/2024

Rule: R9-10-1302. Administration C. An administrator shall:

1. Ensure that policies and procedures are established, documented, and implemented that: t. Cover restraint and seclusion;
Evidence: Based on a review of policy and procedures, observation, facility documents, medical records, and staff interview, the Department determined policies and procedures were not correctly implemented in the application of a patient restraint. This deficient practice resulted in a patient falling and needing further evaluation for injuries.

Findings: A review of the “Behavioral Emergency – Code Grey Situation” revealed “.Any staff member confronted with or witnessing a combative situation should initiate a Code Grey, and begin de-escalation strategies consistent with NVCI (Non-Violent Crisis Intervention).The Code Gray Response Team.De-escalate potentially violent behavior..” A review of the “Seclusion or Restraint” policy last reviewed on September 30, 2021 revealed “.Purpose To establish and implement guidelines for the safe utilization of seclusion or restraint..Application of Restraint.The type or technique of restraint used must be the least restrictive intervention effective to protect the resident or others from harm..Releasing a secluded or restrained Resident.A secluded or restrained resident is released as soon as the resident exhibits behaviors as defined by the release criteria.upon termination of the emergency necessitating the seclusion or restraint.” A review of the “Incident Reports” policy last reviewed on July 29, 2020 revealed “.Policy The Arizona Community Protection and Treatment Center requires the electronic submission of an Incident Report for all events which are significant.These events are to be reported fully, accurately.by the person with the greatest knowledge of the event, in order to provide dependable documentation for possible further investigation and action..Incomplete or inaccurate Incident Reports will be sent back to the originator for correction..The Quality Management Team reviews all Incident Reports each business day, dispositions the Incident Reports for additional review.and codes them appropriately for external reporting purposes..” Observation of the video surveillance without sound from the incident on May 26, 2023, revealed Patient # 11 approach a seated Patient # 4 and berate him face to face while standing over him. Employee # 11 walks directly in front of the two patients at this point heading into the dayroom. Employee # 11 then returns the way he came passing in front of the two patients again but still does not intervene or attempt to de-escalate. Employee # 18 is nearby in the nursing bubble watching the event but also does not attempt to de-escalate the potentially violent behavior. Patient # 11 then begins to punch the still seated Patient #

4. Staff respond to the code including Employee # 10, who uses a non-approved NVCI hold on Patient # 11 and does not coordinate their physical restraint attempt with Employee # 11, leading to Patient # 11 falling to the ground and breaking free of the physical restraint. A review of the facility document “Incident Report: ASH-2023-2299” revealed “.(Patient # 11) approached him and placed his hands around (Patient # 5’s) throat, and started choking him.Several staff arrived on the scene and assisted with separating (Patient # 11) and (Patient # 4)..” The “Incident Report: ASH-2023-2299” fails to mention the fall to the ground by Patient # 11 after the initial attempted physical restraint. A review of the “Incident Report: ASH-2023-2299” revealed two quality management reviews on May, 30, 2023 with both had “.No recommendations.” followed by a supervisor review on June 6, 2023 and an additional review by social work on June 16, 2023 which both also determined “.No recommendations.” A review of the medical records of Patient # 4 and Patient # 11 on March 29, 2024, revealed evidence of progress notes, seclusion and restraint logs and nursing assessments regarding the incident on May 26, 2023 between the two patients. A review of the seclusion and restraint log for Patient # 11 dated May 26, 2023 revealed “.(Patient # 11) reported pain his left shoulder and elbow. (Patient # 11) was sent to Valleywise ED for further evaluation as a precaution..” A review of a progress notes for Patient # 11 dated May 26, 2023 revealed “.Resident reported injuries sustained from his continued struggling against a code gray.restraint that required multiple staff to control him.guarding/pain at his left shoulder and elbow..He will be sent to the ER this evening for evaluation..” Employee # 1 confirmed in an interview on March 28, 2024, that Patient # 11 was sent to the emergency room for an evaluation on May 26, 2023 and returned on May 27, 2023. Date permanent correction will be complete: 2024-04-25

Compliance (Annual) on 3/18/2025

Rule: R9-10-1302.C.1.z. Administration C. An administrator shall:

1. Ensure that policies and procedures are established, documented, and implemented that: z. Include equipment inspection and maintenance;
Evidence: Based on observation during facility tour conducted on March 14, 2024, review of facility documents, request for facility policy and procedure, and employee interview during facility tour, the Department determined that the administrator failed to ensure Daily Medical Emergency Cart/AED Inspection Logs for both Acacia and Mesquite units were completed accurately. This deficient practice could result in emergency medical equipment not functioning properly, posing a risk to the health and safety of patients.

Findings: Facility documents titled “Daily Emergency Medical Cart/AED Inspection Log” posted within staff offices for both Acacia and Mesquite units, observed during facility tour, presented with entries for the last “cart opened and contents checked” date documented on Day 17 of March 2025. The date of review for the facility documents was March 14, 2025. Facility policy and procedure addressing completion of the “Daily Emergency Medical Cart/AED Inspection Log” was requested. None was provided. Employees #1 and #3 confirmed in joint interview, conducted on March 14, 2025, that the “Daily Emergency Medical Cart/AED Inspection Log” posted within staff offices for both Acacia and Mesquite units presented with entries for the last “cart opened and contents checked” date documented on Day 17 of March 2025. Plan of Correction Name, title and/or Position of the Person Responsible Sheridyn Miller, ACPTC Director/Michelle Dunsworth, Chief Nursing Officer Date temporary correction was implemented Date permanent correction will be complete 2025-03-31 Temporary Solution Permanent Solution The Medical Equipment and Materials Management Plan identifies the procedures for identifying malfunctions with medical equipment. It also defines the process for restocking and reloading emergency carts as well as training and emergency medical drills. The Emergency Codes policy defines the process for Medical Alert and Code Blue Response. Additionally, a policy was established to include a process to ensure proper function for the AED device. Code cart education is also conducted annually with nursing personnel. The Chief Nursing Officer (CNO) issued education to all Nursing personnel to educate staff of the expectation for daily checks of emergency carts and the specific steps to take when checking the equipment on the emergency carts. In addition to the notification and education, Nursing personnel will be required to sign an attestation to ensure that all Nursing personnel are in receipt of the information and understanding the established process. This will be completed 3/31/25. Starting on 3/31/25, the Psychiatric Nurse Unit Manager (PNUM) will be conducting daily audits each business day to ensure emergency carts were checked during the proceeding night shift. Additionally, an audit will be conducted of video footage to observe staff checking emergency carts during the date and time documented on the Emergency Cart Log. Upon discovery of non-compliance during the audit, the PNUM will immediately follow up with staff to provide education. The PNUM will report audit findings to the ACPTC Director and the CNO. Daily audits will continue for at least 90 days or until policy requirements are being met and compliance is sustained. Monitoring Nursing leadership will continue to monitor adherence to the established process of checking emergency carts. The PNUM will continue to report findings from daily audits until the requirements are being met and compliance has been sustained. Audit findings will also be reported to ACPTC Quality Council quarterly. The Compliance Department will also include emergency cart checks in the ongoing performance audits/mock surveys as an additional evaluation of sustained compliance. The “Emergency & Safety Standards/Environmental/Physical Plant” performance audit, inclusive of emergency response and environment of care policy requirements, is scheduled for February 2026.

Complaint on 2/22/2023 – 3/10/2023

No violations noted.

Compliance (Annual) on 2/22/2023 – 3/10/2023

No violations noted.

Complaint on 11/13/2023 – 11/15/2023

No violations noted.

Complaint on 10/12/2023 – 10/24/2023

No violations noted.

BACK TO LIFE, INCORPORATED
6420 West Cocopah Street, Phoenix, AZ 85043

Compliance (Annual) on 8/8/2023

Rule: G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes:

3. Documentation of: d. The individual’s license or certification, if the individual is required to be licensed or certified in this Article or policies and procedures;
Evidence: Based on record review and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of the individual’s license, for one of seven personnel records sampled.

Findings:

1. A review of E4’s personnel record revealed E4 was the facility’s registered nurse. However, documentation of E4’s nursing license was not available for review.

2. In an interview, E1 reported E4 had a nursing license, and was not sure why the nursing license was not in E4’s personnel record.

3. In an interview, E1 acknowledged E1 failed to ensure a personnel record was maintained for each personnel member to include documentation of the individual’s license. Date permanent correction will be complete: 2023-08-09

Rule: G. An administrator shall ensure that a
Evidence: Based on documentation review, record personnel record is maintained for each personnel member, employee, volunteer, or student that includes:

3. Documentation of: h. Cardiopulmonary resuscitation training, if required for the individual according to R9-10- 703(C)(1)(e); i. First aid training, if required for the individual according to this Article or policies and procedures; and review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of cardiopulmonary resuscitation (CPR) training, if required for the individual according to R9-10-703(C)(1)(e), and first aid training, for one of seven personnel members sampled. The deficient practice posed a risk if E3 was unable to meet a resident’s needs during an emergency or an accident.

Findings:

1. A review of facility documentation revealed a policy and procedure (dated March 2020) titled “First Aid, CPR, and prevention and support instruction.” The policy stated “Employees will be notified prior to the expiration of their First Aid, CPR, or Prevention and Support training and will need to schedule time to attend the trainings annually.”

2. A review of E1’s personnel record revealed a CPR/First Aid card. However, the CPR/First Aid card expired August 1, 2023.

3. In an interview, E1 acknowledged E1 failed to ensure a personnel record was maintained for each personnel member to include documentation of CPR training and first aid training. Date permanent correction will be complete: 2023-08-09

Rule: A. Except for a behavioral health outdoor program, an administrator shall ensure that the premises and equipment are sufficient to accommodate:

2. An individual admitted as a resident by the behavioral health residential facility.
Evidence: Based on observation, record review and interview, the administrator failed to ensure the premises was sufficient to accomodate an individual admitted as a resident by the behavioral health residential facility. Findings include:

1. The Compliance Officer observed an opening in the facility’s backyard wall which allowed unimpeded access into and out of the backyard.

2. A review of R2’s medical record revealed a facility document titled “Pre- admission profile sheet.” The document stated R2 “leaves house unauthorized.”

3. In an interview, E1 acknowledged E1 failed to ensure the premises was sufficient to accomodate an individual admitted as a resident by the behavioral health residential facility. Date permanent correction will be complete: 2023-08-10

Findings:

Compliance (Annual) on 7/23/2024

Rule: C. An administrator shall ensure that:

3. Policies and procedures are reviewed at least once every three years and updated as needed;
Evidence: Based on documentation review and interview, the administrator failed to ensure policies and procedures were reviewed and updated at least once every three years. The deficient practice posed a risk as policies and procedures reinforce and clarify the health care institution’s standards.

Findings:

1. A review of Department documentation revealed the facility’s perpetual license was effective on September 20, 2019.

2. A review of facility documentation revealed a policy and procedure manual dated April 5, 2018.

3. A review of facility documentation revealed documentation to demonstrate the policies and procedures were reviewed and updated at least once every three years was not available for review.

4. In an interview, E2 reported the policies and procedures were always reviewed, but have not been updated.

5. In an interview, E2 acknowledged the the administrator failed to ensure policies and procedures were reviewed and updated at least once every three years. Date permanent correction will be complete: 2024-07-23

1. At least one personnel member who is present at the behavioral health residential facility during hours of operation of the behavioral health residential facility, and
Evidence: Based on documentation review, and interview the administrator failed to ensure at least one personnel member present at the behavioral health facility during hours of operation had valid cardiopulmonary resuscitation (CPR) training. The deficient practice posed a health and safety risk to residents if facility staff were unable to ensure the health and safety of a resident during an emergency. Findings include:

1. A review of E4’s personnel record revealed documentation of CPR training. However, the CPR training card was through the NationalCPRfoundation, an online CPR training program dated January 7, 2024.

2. A review of the facilities personnel schedule for July 2024 revealed E4 worked alone on July 22, and July 23 from 10 pm to 8 am.

3. In an interview, E2 reported E2 was unaware the facility accepted online CPR training for E4. E2 acknowleged the administrator failed to ensure at least one personnel member present at the behavioral health facility during hours of operation had CPR training. Date permanent correction will be complete: 2024-10-28

Findings:

Rule: B. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, a registered dietitian or director of food services shall ensure that:

2. A food menu: a. Is prepared at least one week in advance, b. Includes the foods to be served each day, c. Is conspicuously posted at least one calendar day before the first meal on the food
Evidence: Based on observation and interview, the registered dietician failed to ensure a food menu was prepared at least one week in advance, included the foods to be served each day and was conspicuously posted at least one calendar day before the first meal on the food menu will be served. The deficient practice posed a risk as the Department was unable to menu will be served, d. Includes any food substitution no later than the morning of the day of meal service with a food substitution, and e. Is maintained for at least 60 calendar days after the last day included in the food menu; determine the food served to the residents was in substantial compliance.

Findings:

1. The Compliance Officer observed a menu conspicuously posted at the facility dated July 2024. The menu consisted of breakfast and snack. However, no additional menu’s for dinner were provided for review.

2. In an interview, E2, stated E2 was unaware of what happened to the dinner menu. E2 acknowledged the registered dietician failed to ensure a food menu was prepared at least one week in advance, included the foods to be served each day and was conspicuously posted at least one calendar day before the fist meal on the food menu will be served. Date permanent correction will be complete: 2024-08-16

BACK TO LIFE, INC
5915 West Roanoke Avenue, Phoenix, AZ 85035

Complaint on 8/1/2024

No violations noted.

Compliance (Annual) on 12/28/2022

Rule: C. An administrator shall ensure that:

5. Unless otherwise stated: a. Documentation required by this Article is provided to the Department within two hours after a Department request; and
Evidence: Based on record review and interview, the administrator failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the licensee did not provide the following: E2’s, E4’s, and E7’s documentation of completed in- service education as required by the facility’s policies and procedures; E2’s cardiopulmonary resuscitation training (CPR); R1’s and R2’s medical history and physical exam or nursing assessment; R2’s treatment plan based upon R2’s behavioral health assessment; R1’s and R2’s documentation of counseling services for November 2022 and December 2022 according to the facility’s scope of services and resident’s treatment plan; and documentation of employee and resident evacuation drills for 2022.

Findings:

1. A review of E2’s (hired in 2022) personnel record revealed documentation of initial training in fall prevention and fall recovery was not available for review.

2. A review of E4’s (hired in 2021) personnel record revealed documentation of initial training in fall prevention and fall recovery was not available for review.

3. A review of E7’s (hired in August 2022) personnel record revealed documentation of initial training in fall prevention and fall recovery was not available for review.

4. A review of E2’s (hired in 2022) personnel record revealed E2 was hired as a behavioral health technician and documentation of current CPR training dated May 12, 2022. However, E2’s current CPR training stated ” .Adult First Aid/CPR/AED Online (Eligible for Skills Session within 90 days).”

5. A review of R1’s (admitted in 2022) medical record revealed a medical history and physical exam dated six days after R1’s date of admission.

6. A review of R2’s (admitted in 2022) medical record revealed a medical history and physical examination or nursing assessment was not available for review. 7. A review of R2’s medical record revealed a treatment plan dated in November 2022. The treatment plan stated ” .weekly family sessions .group counseling .2xs a week .” However, R2’s treatment plan did not include the amount and frequency of individual counseling services. 8. A review of R1’s medical record revealed documentation of the following counseling services provided to R1: – Group counseling: December 20, 2022; and – Individual counseling: November 3, 2022, November 10-11, 2022, November 17, 2022, November 21-22, 2022, November 30, 2022, December 1, 2022, December 6, 2022, December 9, 2022, and December 15, 2022. 9. A review of R2’s medical record revealed documentation of the following counseling services provided to R2: -Group counseling: December 20, 2022; -Individual counseling: November 1, 2022, November 4, 2022, November 9-10, 2022, November 17, 2022, November 23, 2022, November 30, 2022, December 1, 2022, December 8, 2022, and December 14-15, 2022; and -Family counseling: November 11, 2022 and December 15, 2022. 10. The Compliance Officer requested to review documentation of evacuation drills for employees and residents. However, documentation was not provided for review. 11. In an interview, E1 acknowledged documentation required by this Article was not provided to the Department within two hours after a Department request. Date permanent correction will be complete: 2022-12-28

Rule: G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes:

3. Documentation of: c. The individual’s completed orientation and in- service education as required by policies and procedures;
Evidence: Based on documentation review, record review and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of the individual’s completed in-service education as required by policies and procedures, for three of seven personnel members sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not in the personnel records during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: R9-10-101.115. “In-service education” means organized instruction or information that is related to physical health services or behavioral health services and that is provided to a medical staff member, personnel member, employee, or volunteer.

1. A review of facility documentation revealed a policy and procedure titled “Fall Prevention and Fall Recovery” (dated August 11, 2022). The policy and procedure stated ” .All staff employed with Back to Life, Inc. who provide direct care services .will be required to complete mandatory training program initially, and continued competency annually .”

2. A review of E2’s (hired in 2022) personnel record revealed documentation of initial training in fall prevention and fall recovery was not available for review.

3. A review of E4’s (hired in 2021) personnel record revealed documentation of initial training in fall prevention and fall recovery was not available for review.

4. A review of E7’s (hired in August 2022) personnel record revealed documentation of initial training in fall prevention and fall recovery was not available for review.

5. In an interview, E1 acknowledged E2’s, E4’s, and E7’s personnel records did not include documentation of the individual’s completed in-service education as required by policies and procedures. Date permanent correction will be complete: 2023-01-26

Findings:

Rule: G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes:

3. Documentation of: h. Cardiopulmonary resuscitation training, if required for the individual according to R9-10- 703(C)(1)(e);
Evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of cardiopulmonary resuscitation (CPR) training, for one of three behavioral health technicians (BHT) sampled. The deficient practice posed a risk if E2 was unable to perform CPR, the Department was unable to determine substantial compliance as the documentation was not in the personnel record during the inspection, and the documentation was not provided within two hours after a Department request. Findings include:

1. A review of facility documentation revealed a policy and procedure titled “First Aid, CPR and Prevention and Support Instruction” (dated March 31, 2022). The policy and procedure stated ” .If an employee does not have current First Aid, CPR or .they will be notified by Administration of the date/time/place of the next scheduled training, it will not be an online course New hires are to have these documents prior to hire date.”

2. A review of E2’s (hired in 2022) personnel record revealed E2 was hired as a BHT and documentation of current CPR training dated May 12, 2022. However, E2’s current CPR training stated ” .Adult First Aid/CPR/AED Online (Eligible for Skills Session within 90 days).”

3. In an interview, E1 acknowledged E2’s personnel record did not include documentation of current CPR training with demonstration. Date permanent correction will be complete: 2022-12-28

Findings:

Rule: A. An administrator shall ensure that:

6. Except as provided in subsection (E)(1)(a), a medical practitioner performs a medical history and physical examination or a registered nurse performs a nursing assessment on a resident within 30 calendar days before admission or within 72 hours after admission and documents the medical history and physical examination or nursing assessment in the resident’s medical record within 72 hours after admission;
Evidence: Based on record review and interview, the administrator failed to ensure a medical practitioner performed a medical history and physical examination or a nurse performed a nursing assessment on a resident within 30 calendar days before admission or within 72 hours after admission, for two of two residents sampled. The deficient practice posed a risk as this information was required for the development and implementation of a treatment plan, per R9-10-708.A.1., the Department was unable to determine substantial compliance as the documentation was not in the medical records during the inspection, and the documentation was not provided within two hours after a Department request.

Findings:

1. A review of R1’s (admitted in 2022) medical record revealed a medical history and physical exam dated six days after R1’s date of admission.

2. A review of R2’s (admitted in 2022) medical record revealed a medical history and physical examination or nursing assessment was not available for review.

3. In an interview, E1 acknowledged the medical history and physical exam for R1 and a medical history and physical exam or nursing assessments for R2 were not performed within 30 calendar days before admission or within 72 hours after admission. Date permanent correction will be complete: 2022-12-28

Rule: A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that:

1. Is based on the medical history and physical examination or nursing assessment required in R9-10-707(A)(6) or (E) (1)(a) and the behavioral health assessment required in R9-10-707(A)(9) or (10) and on- going changes to the behavioral health assessment of the resident;
Evidence: Based on record review and interview, the administrator failed to ensure a treatment plan was developed for each resident based on the behavioral health assessment required in R9- 10-707(A)(9) or (10), for one of two residents sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the required documentation was not in the medical record during the inspection, and the documentation was not provided within two hours after a Department request.

Findings:

1. A review of R2’s medical record revealed a behavioral health assessment dated in October 2022. The behavioral health assessment stated “Interviewers Recommendations: Individual and group counseling 1-2xs weekly .”

2. A review of R2’s medical record revealed a treatment plan dated in November 2022. The treatment plan stated ” .weekly family sessions .group counseling .2xs a week .” However, R2’s treatment plan did not include the amount and frequency of individual counseling services.

3. In an interview, E1 acknowledged R2’s treatment plan was not based upon R2’s behavioral health assessment. Date permanent correction will be complete: 2022-12-28

Rule: B. An administrator shall ensure that counseling is:

1. Offered as described in the behavioral health residential facility’s scope of services,

2. Provided according to the frequency and number of hours identified in the resident’s treatment plan, and

3. Provided by a behavioral health professional or a behavioral health technician.
Evidence: Based on documentation review, record review and interview, the administrator failed to ensure counseling was provided according to the frequency and number of hours identified in the resident’s treatment plan, for two of two residents sampled. The deficient practice posed a risk if a resident did not receive treatment to cure, improve, or palliate their behavioral health issue at the health care institution, the Department was unable to determine substantial compliance as the documentation was not in the medical records during the inspection, and the documentation was not provided within two hours after a Department request.

Findings:

1. A review of facility documentation revealed a policy and procedure titled “Scope of Services.” The policy and procedure stated, ” .Services available will be .individual, family and group counseling.”

2. A review of facility documentation revealed a policy and procedure titled “Counseling Services.” The policy and procedure stated, ” .The type and amount of counseling is based on the assessment process and the subsequent individual treatment plan .”

3. A review of R1’s medical record revealed a treatment plan dated in October 2022. The treatment plan stated “[R1] will work with the agency therapist in individual sessions 2xs a week . [R1] will be provided family sessions 2xs a month .[R1] will be provided with group counseling .2xs a week .”

4. The Compliance Officer requested to review group counseling, individual counseling, and family counseling for the months of November 2022 and December 2022 for R1 and R2.

5. A review of R1’s medical record revealed documentation of the following counseling services provided to R1: – Group counseling: December 20, 2022; and – Individual counseling: November 3, 2022, November 10-11, 2022, November 17, 2022, November 21-22, 2022, November 30, 2022, December 1, 2022, December 6, 2022, December 9, 2022, and December 15, 2022.

6. A review of R2’s medical record revealed a treatment plan dated in November 2022. The treatment plan stated ” .weekly family sessions .group counseling .2xs a week .” 7. A review of R2’s medical record revealed documentation of the following counseling services provided to R2: -Group counseling: December 20, 2022; -Individual counseling: November 1, 2022, November 4, 2022, November 9-10, 2022, November 17, 2022, November 23, 2022, November 30, 2022, December 1, 2022, December 8, 2022, and December 14-15, 2022; and -Family counseling: November 11, 2022 and December 15, 2022. 8. In an interview, E1 acknowledged counseling was not provided according to the facility’s scope of services and according to the frequency and number of hours identified in the resident’s treatment plan. Date permanent correction will be complete: 2023-01-31

Rule: B. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that:

1. A review of Department documentation revealed the facility was licensed in 2006.

2. A review of facility documentation revealed a daily staffing schedule for December 2022. The daily staffing schedule revealed the facility maintained three shifts: -8AM-2PM; -2PM- 10PM; and -9:45PM-8AM.

3. The Compliance Officer requested to review documentation of evacuation drills for employees and residents. However, documentation was not provided for review.

4. In an interview, E1 reported the facility conducted monthly “fire drills” and was unable to locate the documentation. Date permanent correction will be complete: 2022-12-28