Angel’s Safe Haven, LLC

Deficiency cited, complaint : R9-10-703.K.9. Administration K. An administrator shall: 9. Evaluate and take action related to unauthorized absences under the quality management program in ...

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 if the children's behavioral health facility did not take action to address unauthorized absences. 1. A review of facility documentation revealed an incident report for R1. The incident report dated February 21, 2026 described E3's observations of a phone call where "[R1] becomes frustrated and upset toward [R1's family member]" and stated, "Staff verbally redirected [R1] at least three times during the phone call, instructing [R1] to communicate respectfully and honestly with [R1's family member]. [R1] was clearly warned that continued inappropriate communication would result in termination of phone privileges for that call. When [R1] continued the behavior, staff directed [R1] to end the call and get off the phone. At that time, [R1] became verbally escalated, raising [R1's] voice and yelling toward staff. Staff instructed [R1] to stop and utilize time to calm down. Following the directive, [R1] ran off from the immediate area. Staff conducted an immediate search of the premises but were unable to locate [R1]. Per protocol, staff contacted the non-emergency line to report the situation and request assistance. Staff will continue to monitor [R1's] phone interactions and provide ongoing redirection and behavioral support to prevent recurrence." 2. A review of ...

Deficiency cited, complaint : R9-10-704.1.a-e. Quality Management An administrator shall ensure that: 1. A plan is established, documented, and implemented for an ongoing quality management ...

Based on documentation review and interview, the administrator failed to establish a plan 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 if reports were not submitted to the governing authority. 1. A review of facility documentation revealed a quality management plan. However, the plan did not include the frequency of submitting a documented report required in subsection (2) to the governing authority. 2. In an interview, E1 reported quality reports on resident care are sent monthly to the insurance plans. 3. In an exit interview, the findings were reviewed with E1, and no additional comments, statements, or documentation were provided regarding the findings.

Deficiency cited, complaint : R9-10-706.B.3.c. Personnel B. An administrator shall ensure that: 3. Sufficient personnel members are present on a behavioral health residential facility's ...

Based on documentation review and interview, the administrator failed to ensure that sufficient personnel members were present on a behavioral health residential facility's premises with the qualifications, experience, skills, and knowledge necessary to ensure the health and safety of a resident. The deficient practice posed a risk as R1 and R2 left the facility unauthorized. 1. A review of facility documentation revealed an incident report for R1. The incident report dated February 21, 2026 described facility personnel's observations of a phone call where "[R1] becomes frustrated and upset toward [R1's family member]" and stated, "Staff verbally redirected [R1] at least three times during the phone call, instructing [R1] to communicate respectfully and honestly with [R1's family member]. [R1] was clearly warned that continued inappropriate communication would result in termination of phone privileges for that call. When [R1] continued the behavior, staff directed [R1] to end the call and get off the phone. At that time, [R1] became verbally escalated, raising [R1's] voice and yelling toward staff. Staff instructed [R1] to stop and utilize time to calm down. Following the directive, [R1] ran off from the immediate area. Staff conducted an immediate search of the premises but were unable to locate [R1]. Per protocol, staff contacted the non-emergency line to report the situation and request assistance. Staff will continue to monitor [R1's] phone interactions and provide ...

Deficiency cited, complaint : R9-10-706.G.3.f. Personnel G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student ...

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 compliance with the requirements in A.R.S. § 8-804(C), for two of two personnel members sampled. The deficient practice posed a risk if E2 and E3 were not qualified to work in a children's behavioral health residential facility. A.R.S. 8-804(C). "C. Licensees that do not contract with the state and that employ persons who provide direct services to children pursuant to title 36, chapter 7.1 must submit to the department of child safety in a manner prescribed by the department of child safety information necessary to conduct central registry background checks. The department of health services shall verify whether licensees, pursuant to title 36, chapter 7.1, have complied with the requirements of this subsection and any rules adopted by the department of health services to implement this subsection." 1. A review of E2's and E3's personnel record revealed no documentation of a Department of Child Safety (DCS) central registry check being completed. 2. In an interview, E1 reported there was no DCS central registry check completed for personnel. E1 started the process to perform the checks while the Compliance Officer was on-site. 3. In an exit interview, the findings were reviewed with E1, and no additional comments, statements, or documentation were provided regarding the findings.

Deficiency cited, complaint : R9-10-716.A.2.b. Behavioral Health Services A. An administrator shall ensure that: 2. If a behavioral health residential facility is licensed to provide ...

Based on documentation review and interview, the administrator failed to ensure that residents admitted to the behavioral health residential facility with limited ability to function independently received continuous protective oversight. The deficient practice posed a risk as R1 and R2 left the facility unauthorized. 1. A review of facility documentation revealed an incident report for R1. The incident report dated February 21, 2026 described facility personnel's observations of a phone call where "[R1] becomes frustrated and upset toward [R1's family member]" and stated, "Staff verbally redirected [R1] at least three times during the phone call, instructing [R1] to communicate respectfully and honestly with [R1's family member]. [R1] was clearly warned that continued inappropriate communication would result in termination of phone privileges for that call. When [R1] continued the behavior, staff directed [R1] to end the call and get off the phone. At that time, [R1] became verbally escalated, raising [R1's] voice and yelling toward staff. Staff instructed [R1] to stop and utilize time to calm down. Following the directive, [R1] ran off from the immediate area. Staff conducted an immediate search of the premises but were unable to locate [R1]. Per protocol, staff contacted the non-emergency line to report the situation and request assistance. Staff will continue to monitor [R1's] phone interactions and provide ongoing redirection and behavioral support to prevent ...

Deficiency cited, complaint : R9-10-716.A.2.b. Behavioral Health Services A. An administrator shall ensure that: 2. If a behavioral health residential facility is licensed to provide ...

Based on observation, record review and interview, the administrator failed to ensure residents admitted to the behavioral health residential facility with limited ability to function independently received continuous protective oversight. The deficient practice posed a risk as the repeated violation shows a pattern of noncompliance to ensure the health and safety of residents. 1. A review of Department documentation revealed the facility was licensed to provide services to individuals under 18 years of age. 2. The Compliance Officer observed, several times throughout the inspection, R1 was left unsupervised in the living room (with toxic chemicals within reach and unlocked doors to which R1 could have left the facility.) E1 and E2 were in the facility's office, with the door partially open, and neither could see R1 in the living room. 3. A review of R1's medical record revealed R1 was a minor admitted to the behavioral health residential facility requiring continuous protective oversight. 4. In an interview with E1, the Compliance Officer reported R1 was left unsupervised and without continuous protective oversight throughout the inspection (by E2 who was working) and demonstrated the current concern to E1. E1 acknowledged E2 should be providing continuous protective oversight at all times and called E2 into the room to oversee R1. 5. In an exit interview, the findings were reviewed with E1 (in person) and E7 (telephonically) and no additional comments or documentation were ...

Deficiency cited, complaint : R9-10-706.B.3.c. Personnel B. An administrator shall ensure that: 3. Sufficient personnel members are present on a behavioral health residential facility's ...

Based on documentation review and interview, the administrator failed to ensure that sufficient personnel members were present on a behavioral health residential facility's premises with the qualifications, experience, skills and knowledge necessary to ensure the health and safety of a resident. The deficient practice posed a risk as R1 did not receive continuous protective oversight, and the repeated violation shows a pattern of noncompliance to ensure the health and safety of residents. 1. A review of facility documentation revealed a document titled "Angels Safe Haven Incident Report," dated December 12, 2025, completed by E1. The report stated "Client [R1] was seated at the kitchen table when [R1] requested to go outside stating [R1] wanted to walk. [R1]'s demeanor was calm. [R1] was unable to view TV due to loss of privileges for being suspended from school. Staff agree to allow [R1] to go outside in the back yard while [staff] observed [R1]. [R1] walked around the yard circling it several times when [R1] jumped on the wall. Staff immediately directed the member to get off the wall. The client ignored the redirection and proceeded to jump over the wall out of the yard. Staff immediately went out the front door with the remaining clients and proceeded to the side of the wall that [R1] had jumped to get [R1] however however [sic] the member had left the area. Staff immediately call [sic] Goodyear PD and proceeded to canvas the area to look for client." 2. In an interview ...

Deficiency cited, complaint : R9-10-706.F.2. Personnel F. An administrator shall ensure that a personnel member, or an employee, a volunteer, or a student who has or is expected to have ...

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 R9-10-113, for one of two personnel members sampled. The deficient practice posed a TB exposure risk to residents. 1. A review of E2's (hired in 2025) personnel record revealed one negative skin test, dated in December 2025. However, a second skin test was not available for review. 2. A review of E2's personnel record revealed a baseline screening and risk assessment, however, the document was not reviewed and signed by a registered nurse or doctor. 3. In an exit interview, the findings were reviewed with E1 (in person) and E3 (telephonically) and no additional comments or documentation were provided for review.

Deficiency cited, complaint : R9-10-706.G.3.e. Personnel G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student ...

Based on observation, 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. § 36-425.03.A.E., for one of two personnel members sampled. The deficient practice posed a risk if E2 was a danger to a vulnerable population, and the repeated violation shows a pattern of noncompliance to ensure the health and safety of residents. 1. The Compliance Officer observed E2 at the behavioral health residential facility during the inspection on December 16, 2025. 2. In an interview, at 10:40 AM, E2 reported E2 worked the previous evening at the behavioral health facility from 9 pm and was scheduled to leave the facility at 9 am. E2 reported being at the facility upon the Compliance Officer's (8:30 AM) arrival but did not answer the door because E2 did not hear the Compliance Officer knocking. 3. A review of facility documentation revealed a daily staffing schedule dated Monday, December 8, 2025 - Sunday, December 14, 2025. The schedule revealed E2 was scheduled to work alone from 9 AM - 6 PM on December 13, 2025 and December 14, 2025. A second daily staffing schedule dated December 15, 2025 - Sunday, December 21, 2025 revealed E2 was scheduled to work on Monday, December 15, 2025 to Tuesday December 16, 2025 from 9 PM - 9 AM and 2 PM - 11 PM on December 16, 2025. 4. A review of E2's personnel record revealed E2 was hired as a ...

Deficiency cited, complaint : R9-10-706.K.3.b. Personnel K. An administrator shall ensure that: 3. There is a daily staffing schedule that: b. Includes documentation of the employees who ...

Based on documentation review, record review and interview, the administrator failed to ensure there was a daily staffing schedule to include documentation of the hours worked by each employee. The deficient practice posed a risk as there was no accurate record to verify sufficient, qualified personnel members and employees were present or available to meet the needs of the residents. 1. A review of facility documentation revealed a daily staffing schedule, dated Monday, December 8, 2025 - Sunday, December 14, 2025. The daily staffing schedule stated E2 was "OFF" on Thursday, December 11, 2025. 2. A review of R1's medical record revealed a document titled "Angel's Safe Haven Provider Daily Progress Note," dated December 11, 2025. The afternoon section was filled out and signed by E2 and stated the following "Client stayed home [R1] was sent home yesterday. Client has sat at dinner table all day + talked to pastor." 3. In an interview E1 acknowledged the daily staffing schedule reflected E2 was "OFF" and not scheduled to work on December 11, 2025, and E2 did actually work on December 11, 2025. 4. In an exit interview, the findings were reviewed with E1 (in person) and E3 (telephonically) and no additional comments or documentation were provided for review.

Deficiency cited, complaint : 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 ...

Based on record review and interview, the administrator failed to ensure a registered nurse (RN) performed a nursing assessment on a resident within 72 hours after admission, for one of one resident sampled. The deficient practice posed a risk of not meeting a resident's needs if no physical examination were completed to assess a resident's needs prior to treatment, and the repeated violation shows a pattern of noncompliance to ensure the health and safety of residents. 1. A review of R1's medical record revealed a document titled "Initial Health Screen," dated in October 2025, signed by the RN. However, the document was dated over a month after R1's admission date. 2. In an exit interview, the findings were reviewed with E1 (in person) and E3 (telephonically) and E3 reported the October 2025 date was made in error and E3 believed the document had been done a few days after R1's admission. E1 acknowledged the document was signed and dated by the RN a month after R1's admission. This is a repeated violation from the compliance inspection conducted on June 19, 2023.

Deficiency cited, complaint : R9-10-708.A.4.c. Treatment Plan A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that: 4. Includes: c. The ...

Based on record review and interview, the administrator failed to ensure a treatment plan was developed and implemented for each resident to include the signature of the resident or the resident's representative, and date signed, or documentation of the refusal to sign, for one of one resident sampled. The deficient practice posed a risk as a treatment plan was not developed to articulate decisions and agreements before treatment was initiated, and the repeated violation shows a pattern of noncompliance to ensure the health and safety of residents. 1. A review of R1's medical record revealed documentation which indicated R1 was under legal guardianship, with R1's guardian acting as R1's representative. 2. A review of R1's medical record revealed a treatment plan, dated in September 2025, with no signature of R1's representative, and date signed, or documentation of the refusal to sign. 3. A review of R1's medical record revealed an email sent to R1's representative, from E3, on October 23, 2025, asking for the treatment plan be signed. R1's guardian responded stating "Good morning. I will send the form back shortly. Thank you." However, documentation of R1's treatment plan signed by R1's representative was not available for review. 4. In a telephonic interview, E3 reported E3 had reached out to R1's representative on numerous occasions to get R1's representative to sign the treatment plan. However, R1's representative never signed R1's treatment plan. 5. In an exit ...

Deficiency cited, complaint : R9-10-716.A.2.b. Behavioral Health Services A. An administrator shall ensure that: 2. If a behavioral health residential facility is licensed to provide ...

Based on record review, documentation review and interview, the administrator failed to ensure residents admitted to the behavioral health residential facility with limited ability to function independently received continuous protective oversight. The deficient practice posed a risk as R1 was not provided continuous protective oversight by the facility personnel at all times and the repeated violation shows a pattern of noncompliance to ensure the health and safety of residents. 1. A review of R1's medical record revealed R1 was a minor admitted to the behavioral health residential facility requiring continuous protective oversight. 2. A review of facility documentation revealed a document titled "Angels Safe Haven Incident Report," dated December 12, 2025, completed by E1. The report stated "Client [R1] was seated at the kitchen table when [R1] requested to go outside stating [R1] wanted to walk. [R1]'s demeanor was calm. [R1] was unable to view TV due to loss of privileges for being suspended from school. Staff agree to allow [R1] to go outside in the back yard while [staff] observed [R1]. [R1] walked around the yard circling it several times when [R1] jumped on the wall. Staff immediately directed the member to get off the wall. The client ignored the redirection and proceeded to jump over the wall out of the yard. Staff immediately went out the front door with the remaining clients and proceeded to the side of the wall that [R1] had jumped to get [R1] however however ...

Deficiency cited, complaint : R9-10-706.B.3.c. Personnel B. An administrator shall ensure that: 3. Sufficient personnel members are present on a behavioral health residential facility's ...

Based on documentation review, record review, and interview, the administrator failed to ensure that sufficient personnel members were present on a behavioral health residential facility's premises with the qualifications, experience, skills, and knowledge necessary to ensure the health and safety of a resident. The deficient practice posed a risk as sufficient staff were not present to meet the unscheduled needs of the resident requiring continuous protective oversight. 1. A review of the facilities' policies and procedures revealed a policy titled "Staffing of Residential Facilities." The policy stated "...The agency shall provide sufficient staff to provide the services, client supervision, and treatment...." 2. A review of facility documentation revealed an incident report dated October 23, 2025. The incident report stated, "....Staff went to the office to get paper. Staff returned from the office and noticed that [R1] had gone and jumped the fence on the side of the house and left the premises. Staff tried to intervene, but [R1] ran down the street and walked left on [street name]. Staff began to follow the client in the van. Staff followed the client to the construction site, located at Encanto Blvd., where staff wasn't able to retrieve [R1]back in staff's possession. [R1] then got into the construction worker's truck, and the construction worker called the police. The police retrieved [R1] and called the CEO and Admin. Staff returned to the house and retrieved the ...

Deficiency cited, complaint : R9-10-706.K.3.b. Personnel K. An administrator shall ensure that: 3. There is a daily staffing schedule that: b. Includes documentation of the employees who ...

Based on observation, documentation review, and interview, the administrator failed to ensure that there was a daily staffing schedule that included documentation of the employees who work each calendar day and the hours worked by each employee. The deficient practice posed a risk as the schedule does not include the correct staffing to verify compliance. 1. The Compliance Officer observed E1 and E2 working at the facility at the time of the inspection. 2. A review of the facilities staffing schedule revealed the current week's schedule. The schedule revealed that on November 4, 2025, and November 5, 2025, E3 was scheduled to work from 9:00 AM to 5:00 PM. 3. In a phone interview, E3 reported E3 was in California and did not work on November 4, 2025, and was not currently at the facility on November 5, 2025, from 9:00 AM to 5:00 PM. 4. In an interview, E2 acknowledged E3 was identified to be working at the facility. E2 acknowledged that the administrator failed to ensure that there is a daily staffing schedule that includes documentation of the employees who work each calendar day and the hours worked by each employee.

Deficiency cited, complaint : R9-10-716.A.2.b. Behavioral Health Services A. An administrator shall ensure that: 2. If a behavioral health residential facility is licensed to provide ...

Based on documentation review, record review, and interview, the administrator failed to ensure that residents admitted to the behavioral health residential facility with limited ability to function independently received continuous protective oversight. The deficient practice posed a risk as a minor child was not supervised by the facility personnel at all times. 1. A review of R1's medical record revealed R1 was a minor admitted to the behavioral health residential facility requiring continuous protective oversight. 2. In an interview, R1 reported leaving the behavioral health facility without notifying staff, reportedly due to an argument with peers. R1 reported that facility staff initially followed R1 after leaving the facility in a van. R1 reported that the staff were not present at the construction site, and R1 was alone with the construction workers for approximately thirty minutes. R1 reported that a police officer picked up R1 from the construction site and brought R1 to the station. 3. A review of an incident report dated October 23, 2025, revealed "....Staff went to the office to get paper. Staff returned from the office and noticed that [R1] had gone and jumped the fence on the side of the house and left the premises. Staff tried to intervene, but [R1] ran down the street and walked left on [street name]. Staff began to follow the client in the van. Staff followed the client to the construction site, located at Encanto Blvd., where staff wasn't able to retrieve ...

Deficiency cited, complaint : R9-10-703.C.2.d. Administration C. An administrator shall ensure that: 2. Policies and procedures for behavioral health services and physical health services ...

Based on documentation review and record review, the administrator failed to document policies and procedures for behavioral health services to protect the health and safety of a resident that covered emergency safety responses (ESR.) The deficient practice posed a risk as a behavioral health residential facility is not authorized to conduct seclusions or restraints. 1. A review of facility documentation revealed an undated policy and procedure titled "Abnormal Behaviors, Behavioral Emergency, Behavioral Management." The document stated "II Policy:...I. Only staff members that have attended and successfully completed a nationally recognized Crisis Prevention Intervention\Emergency Safety Response course may use physical restraint on a client/consumer who is a danger to herself to prevent them from harm or harming others. J. Staff certified in Crisis Prevention Intervention\Emergency Safety Response use the least restrictive means of restraint to ensure the care, welfare, safety and security for the client/consumer and others." 2. A review of facility documentation revealed an undated policy and procedure titled "Emergency Safety Response/Seclusion and Restraint." 3. A review of facility documentation revealed an undated training manual for the Emergency Safety Response curriculum, titled "Therapeutic Crisis Intervention (TCI) - Student Workbook, Seventh Edition." The curriculum discussed and trained on the use of restraints. The curriculum stated "The use of physical ...

Deficiency cited, complaint : R9-10-706.G.3.h. Personnel G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student ...

Based on record review and interview, the administrator failed to ensure a personnel record was maintained to include documentation of cardiopulmonary resuscitation (CPR) training. The deficient practice posed a risk as the repeated violation shows a pattern of noncompliance to ensure the health and safety of residents. 1. A review of facility documentation revealed daily staffing schedules, dated October 13 -19, 2025 and October 20 - 26, 2025. The staffing schedules revealed E5 worked the 11:00 PM-8:00 AM shifts alone at the facility as a behavioral health technician. 2. A review of E5's personnel record revealed a Healthcare Provider CPR/AED: Adult, Child & Infant + First Aid" certificate, dated January 20, 2025. However, the training was from an online program and did not include demonstration of CPR. 3. In an exit interview, E1 acknowledged the CPR training document in E5's personnel record was from an online program and did not include a demonstration. E1 reported to be under the impression E5 had an additional CPR training document, however, E1 was unable to provide the CPR demonstration documentation for review. This is a repeated violation from the compliance inspection conducted on May 31, 2022; the compliance inspection conducted on June 19, 2023; the complaint investigation/compliance inspection conducted on June 5, 2024; and the complaint investigation conducted on September 26, 2024.

Deficiency cited, complaint : R9-10-706.J.1. Personnel J. An administrator shall ensure that the following personnel members have first-aid and cardiopulmonary resuscitation training ...

Based on documentation review, 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 of the behavioral health residential facility who had cardiopulmonary resuscitation (CPR) training to include a demonstration. The deficient practice posed a risk as the repeated violation shows a pattern of noncompliance to ensure the health and safety of residents. 1. A review of facility documentation revealed daily staffing schedules, dated October 13 - 19, 2025 and October 20 - 26, 2025. The staffing schedules revealed E5 worked the 11:00 PM-8:00 AM shifts alone at the facility as a behavioral health technician. 2. A review of E5's personnel record revealed a Healthcare Provider CPR/AED: Adult, Child & Infant + First Aid" certificate, dated January 20, 2025. However, the training was from an online program and did not include a demonstration. 3. In an exit interview, E1 acknowledged the CPR training document in E5's personnel record was from an online program and did not include a demonstration. E1 reported to be under the impression E5 had an additional CPR training document, however, E1 was unable to provide CPR demonstration documentation for review. E1 acknowledged E5 worked shifts alone at the behavioral health facility. This is a repeat violation from the compliance inspection conducted on June 19, 2023; and the complaint investigation and compliance ...

Deficiency cited, complaint : R9-10-708.A.6.d. Treatment Plan A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that: 6. Is reviewed and ...

Based on documentation review, record review and interview, the administrator failed to ensure a treatment plan was updated when a resident had a significant change in condition or experienced an event that affected treatment. The deficient practice posed a risk as a treatment plan was not updated to articulate decisions and agreements of services to be provided, and posed a risk if the resident's treatment needs were not consistent with the services BH6115 was authorized and able to provide. 1. A review of R1's medical record revealed an untitled document, dated October 9, 2025. The document stated the following "The member currently does not have 24-hour supervision, and the BHRF is unable to provide this level of care. Even with 1:1 staffing, the facility reports concerns about their capacity to safely manage the member's behaviors. A BHIF provides the locked, highly structured and medically supervised environment required to ensure [R1's] safety, stabilize [R1's] behaviors and deliver intensive, daily therapeutic support." Additionally, the document stated "Current clinical and behavioral concerns: Elopement: has left the current BHRF approximately 10 times, at times requiring crisis intervention...Suicidal statements: Expresses self-harm thoughts to avoid tasks or gain attention, later recanting...Next steps: The High Needs Case Coordinator will initiate a referral for Behavioral Health Inpatient Facility (BHIF) placement to ensure the member receives the appropriate ...

Deficiency cited, complaint : R9-10-709.C. Discharge C. An administrator shall ensure that a resident is discharged from a behavioral health residential facility when the resident's ...

Based on record review, documentation review and interview, the administrator failed to ensure a resident was discharged from a behavioral health residential facility when the resident's treatment needs were not consistent with the services that the behavioral health residential facility was authorized and able to provide. The deficient practice posed a risk if R1 was a danger-to-self or a danger-to-others. R9-10-101.36. “Behavioral health residential facility” means a health care institution that provides treatment to an individual experiencing a behavioral health issue that: a. Limits the individual’s ability to be independent, or b. Causes the individual to require treatment to maintain or enhance independence. 1. A review of R1's medical record revealed an untitled document, dated October 9, 2025. The document stated the following "The member currently does not have 24-hour supervision, and the BHRF is unable to provide this level of care. Even with 1:1 staffing, the facility reports concerns about their capacity to safely manage the member's behaviors. A BHIF provides the locked, highly structured and medically supervised environment required to ensure [R1's] safety, stabilize [R1's] behaviors and deliver intensive, daily therapeutic support." Additionally, the document stated "Current clinical and behavioral concerns: Elopement: has left the current BHRF approximately 10 times, at times requiring crisis intervention...Suicidal statements: Expresses self-harm thoughts ...

Deficiency cited, complaint : R9-10-706.B.3.c. Personnel B. An administrator shall ensure that: 3. Sufficient personnel members are present on a behavioral health residential facility's ...

Based on documentation review and interview, the administrator failed to ensure that sufficient personnel members were present on a behavioral health residential facility's premises with the qualifications, experience, skills, and knowledge necessary to to ensure the health and safety of a resident. The deficient practice posed a risk as a resident was at the premise when no personnel members were present. 1. A review of facility documentation revealed an incident report dated October 16, 2025. The incident report stated, "[E4] arrived about 10 min late to my shift due to an accident on the freeway. Upon arrival Goodyear PD was on the scene with [R1] and alluded [sic] the school had dropped [R1] off early due to [R1's] behaviors on the van. The other staff had left with the other clients to the Dr. appointments. I contacted management for PD and [sic] took over care of [R1]. No other issues to report." 2. A review of facility documentation revealed a staffing schedule. The staffing schedule revealed on October 16, 2025 E1 was scheduled to work 5:00 PM-9:00 PM for 1:1 coverage with R1, E2 was scheduled 8:00 AM-2:00 PM, E3 was scheduled 8:00 AM-6:00 PM, and E4 was scheduled 4:00 PM-9:00 PM. 3. A review of facility documentation revealed policies and procedures. The "STAFFING OF RESIDENTIAL FACILITIES-EMPLOYEES... Policy:" stated, "A. The agency shall provide sufficient staff to provide the services, client supervision, and treatment; and to provide ancillary services to meet ...

Deficiency cited, complaint : R9-10-706.K.1. Personnel K. An administrator shall ensure that: 1. At least one personnel member is present and awake at the behavioral health residential ...

Based on documentation review and interview, the administrator failed to ensure at least one personnel member was present and awake at the behavioral health residential facility when a resident was on the premises. The deficient practice posed a risk as a resident was at the premise when no personnel members were present. 1. A review of facility documentation revealed an incident report dated October 16, 2025. The incident report stated, "[E4] arrived about 10 min late to my shift due to an accident on the freeway. Upon arrival Goodyear PD was on the scene with [R1] and alluded [sic] the school had dropped [R1] off early due to [R1's] behaviors on the van. The other staff had left with the other clients to the Dr. appointments. I contacted management for PD and [sic] took over care of [R1]. No other issues to report." 2. A review of facility documentation revealed a staffing schedule. The staffing schedule revealed on October 16, 2025 E1 was scheduled to work 5:00 PM-9:00 PM for 1:1 coverage with R1, E2 was scheduled 8:00 AM-2:00 PM, E3 was scheduled 8:00 AM-6:00 PM, and E4 was scheduled 4:00 PM-9:00 PM. 3. A review of facility documentation revealed policies and procedures. The "STAFFING OF RESIDENTIAL FACILITIES-EMPLOYEES... Policy:" stated, "K. The agency shall ensure that at least one (1) staff member is present and awake at the facility at all times when a client/consumer is on the premise." 4. In an interview, E1 reported no personnel members were on the premises when ...

Deficiency cited, complaint : R9-10-720.C.3. Emergency and Safety Standards C. An administrator shall: 3. Maintain documentation of a current fire inspection.

Based on observation and interview, the administrator failed to ensure a current fire inspection report was maintained. The deficient practice posed a potential risk to the health and safety of a resident in the event of a fire if hazards were not identified and corrected and standards expected of the facility were not followed. 1. The Compliance Officer observed an expired Fire Permit was posted in the facility. 2. The Compliance Officer requested to review a current fire inspection report. However, a current fire inspection report was not provided while the Compliance Officer was on-site. 3. In an exit interview, the findings were reviewed with E1, and no additional comments, statements, or documentation were provided regarding the findings.

Deficiency cited, complaint : R9-10-706.B.3.c. Personnel B. An administrator shall ensure that: 3. Sufficient personnel members are present on a behavioral health residential facility's ...

Based on documentation review and interview, the administrator failed to ensure sufficient personnel members were present on the behavioral health residential facility’s premises with the qualifications, experience, skills, and knowledge necessary to ensure the health and safety of residents. The deficient practice posed a risk to resident safety, as inadequate staffing contributed to a resident leaving the facility unsupervised. 1. A review of facility documentation revealed an incident report dated September 30, 2025 stated "Client [R1] asked to use the restroom. While staff [E4] was conversing and interacting with other clients, [R1] walked out the front door. Staff [E4] went outside to the front to look for [R1] and noticed [R1] was sitting in the house van. Staff [E4] redirected client [R1] to get out of vehicle, which [R1] complied and got out. Staff [E4] directed [R1] to come back in the house , which [R1] did not comply and began walking away from the house east bound down Cambridge Ave towards Bullard. Staff [E4] went and got the other 3 clients inside the house and began looking and following [R1] when [R1] was no longer in view. After catching up with [R1] at Bullard and Cambridge intersection, [R1] became combatant [sic] with 2 of the other clients [R2] and [R3] by hitting them when they approached. Staff [E4] attempted to guide and direct [R1] back home, which [R1] refused and began kicking [R1] shoes off, pulling down [R1] pants, and started shouting that [R1] ...

Deficiency cited, complaint : R9-10-716.A.7.a. Behavioral Health Services A. An administrator shall ensure that: 7. A resident does not: a. Use or have access to any materials, furnishings ...

Based on documentation review and record review, the administrator failed 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 a metal bar while admitted into a behavioral health residential facility, in contradiction to their behavioral health issue.  1. A review of facility documentation revealed a incident report dated September 19, 2025. The incident report stated "Client [R1] peed on the floor after undressing and touching [R1] private parts. Client [R1] played in [R1] urine client [R1] later was naked in room and trashing [R1's] room and breaking the blinds. Staff [E3] told [R1] to put clothes on and [R1] complied by continue to damage property and was disorderly. Staff [E3] had to remove a medal [sic] bar from client [R1] when client [R1] tried to use it as a weapon on staff [E3]. Client [R1] was placed in a hold for 5 minutes. Police and Fire were notified but did not do their jobs concerning the disorderly conduct and property damage staff [E3] tried to contact Fire for client [R1] to be evaluated and fire said that was not their job. Struggles with client [R1] continued for 3 hours. CPI hold x5 (3 minutes at a time for safety)." 2. A review of R1's medical record (admitted 2025) revealed a behavioral health assessment dated March 3, 2025. The assessment revealed R1 “was recently discharged ...

Deficiency cited, complaint : R9-10-716.E.2.c. Behavioral Health Services E. An administrator shall ensure that: 2. Within 24 hours after an emergency safety response is used for a ...

Based on documentation review, record review, and interview, the administrator failed to ensure that within 24 hours after an emergency safety response was used for a resident, the specific emergency safety response used was entered into the resident’s medical record. This deficient practice posed a risk of incomplete documentation regarding the use of emergency safety interventions. 1. A review of facility documentation revealed an incident report dated September 19, 2025, stated "Client [R1] peed on the floor after undressing and touching [R1] private parts. Client [R1] played in [R1] urine client later was naked in room and trashing [R1's] room and breaking the blinds. Staff [E3] told [R1] to put clothes on and [R1] complied by continue to damage property and was disorderly. Staff had to remove a medal [sic] bar from client [R1] when client [R1] tried to use it as a weapon on staff [E3]. Client [R1] was placed in a hold for 5 minutes. Police and Fire were notified but did not do their jobs concerning the disorderly conduct and property damage staff [E3] tried to contact Fire for client to be evaluated and fire said that was not their job. Struggles with client [R1] continued for 3 hours. CPI hold x5 (3 minutes at a time for safety)." However, the incident report did not include the specific emergency response used. 2. A review of R1’s medical record revealed no documentation of the specific emergency safety response used following the incident on September 19, 2025. The ...

Deficiency cited, compliance (annual) : R9-10-113.A.2.a-f. Tuberculosis Screening A. If a health care institution is subject to the requirements of this Section, as specified in an Article in this ...

Based on documentation review and interview, the health care institution's chief administrative officer failed to establish and document tuberculosis (TB) infection control activities to include annual training and education related to recognizing the signs and symptoms of TB to individuals employed by the health care institution. The deficient practice posed a potential TB exposure risk to residents. 1. A review of facility documentation revealed no TB infection control activities to include, annual training and education related to recognizing the signs and symptoms of TB. 2. In a joint interview, E1 and E2 reported the facility’s TB education program was at another location and was not available for review.  3. In a joint exit interview, the findings were reviewed with E1 and E2, and no further documentation or comment was provided.

Deficiency cited, compliance (annual) : R9-10-706.G.3.g. Personnel G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student ...

Based on record review, documentation review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel member that includes documentation of clinical oversight as required by R9-10-115 for a behavioral health technician, for two of five personnel records sampled. The deficient practice posed a risk if individuals not qualified to provide behavioral health services did not receive training from a licensed individual. 1. A review of E2's (hired as a behavioral health technician) and E4's (hired as a behavioral health technician) personnel records revealed no documentation of clinical oversight from a behavioral health professional (BHP). 2. A review of facility documentation revealed group counseling sessions. The dates of the counseling were from July 3, 2025, through August 7, 2025, and were conducted by E2 and E4. 3. In an interview with E1 and E2, it was reported that the facility had been closed and reopened in July. E2 reported clinical oversight had not been conducted since the facility reopened. 4. In an exit interview, the findings were reviewed with E1 and E2 and no additional comments, statements, or documentation were provided regarding the findings.

Deficiency cited, compliance (annual) : R9-10-718.C.6.a. Medication Services C. If a behavioral health residential facility provides assistance in the self-administration of medication, an ...

Based on record review and interview, the behavioral health residential facility failed to provide assistance in the self-administration of medication and ensure that the resident was taking the medication in compliance with an order, for one of two resident records sampled. 1. A review of R2's medical record revealed a medication order from a medical practitioner for “Clondine HCI 0.1 mg tablet - Take 1 tab po qhs”. 2. A review of R2's medical record revealed a medication administration record (MAR), which revealed the aforementioned medication was taken at 8:00 AM and not at bedtime. 3. A review of R2's medical record revealed a medication order from a medical practitioner for “Hydroxyzine pamoate 25 mg capsule - Take 1 tab po q 6hrs prn anxiety." 4. A review of R2's MAR revealed the description and instructions stated on the MAR were incorrect. The MAR stated, "Hydroxyzine. Dosage: 50mg. Instructions/Route: Every six hours PRN.” 5. In an interview, E2 reported the current medication orders were the most recent orders. 6. In an exit interview, the findings were reviewed with E1 and E2 and no additional comments, statements, or documentation were provided regarding the findings.

Deficiency cited, complaint : 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 ...

Based on record review and interview, the administrator failed to ensure a treatment plan was developed and implemented for each resident to include the signature of the resident or the residents representative, and 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. 1. A review of R1's (admitted in 2025) medical record revealed a treatment plan (dated in 2025). Hohwever, the treatment plan did not include the signature of R1 or R1's representative, and date signed, or documentation of the refusal to sign. 2. In a joint exit interview, the findings were reviewed with E1 and E6 and no additional comments or statements were provided regarding the findings. This Rule was cited on August 27, 2024. A letter sent to the licensee, on September 27, 2024, 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 and still requires that you make corrections to all violations noted in the SOD."

Deficiency cited, complaint : 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 ...

Based on record review, documentation review, and interview, the administrator failed to ensure a treatment plan completed by a behavioral health technician (BHT), was reviewed and signed by a behavioral health professional (BHP) within 24 hours after the completion of the treatment plan, for one of two residents 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. 1. A review of R1's (admitted in 2025) medical record revealed a treatment plan (dated in 2025) completed by E1. However, the document was not reviewed and signed by a BHP. 2. A review of E1's personnel record revealed E1 was not a BHP. 3. A review of facility documentation revealed an email from E6 was sent to E2 on April 7, 2025 at 11:18AM. The email stated "May you please sign and send back the treatment plan asap." This email was sent more than 24 hours after R1's treatment plan was completed. 4. In a joint exit interview, the findings were reviewed with E1 and E6 and no additional comments or statements were provided regarding the findings. This Rule was cited on August 27, 2024. A letter sent to the licensee, on September 27, 2024, 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 and still requires that you make ...

Deficiency cited, complaint : C. An administrator shall ensure that: 1. Policies and procedures are established, documented, and implemented to protect the health and safety of a resident ...

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. 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 ...

Deficiency cited, complaint : C. An administrator shall ensure that: 5. Unless otherwise stated: a. Documentation required by this Article is provided to the Department within two hours ...

Based on record review and interview, the administrator failed to ensure documentation required by Article 7 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 compliance. 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 ...

Deficiency cited, complaint : B. An administrator shall ensure that: 3. Sufficient personnel members are present on a behavioral health residential facility's premises with the ...

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. 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 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 ...

Deficiency cited, complaint : G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes: 3. ...

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.) §§ 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. A.R.S. §§ 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. §§ 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. §§ 36-425.03(E) (dated September 12, 2024). However, the document stated " ... True False 1. I am not ...

Deficiency cited, complaint : G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes: 3. ...

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. 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. ... M. The agency shall provide one (1) staff member who has current documentation of successful completion of First Aid and CPR training for adolescents ..." 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 ...

Deficiency cited, complaint : G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes: 3. ...

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. 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: 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, baseline screening, on or before the date specified in the applicable Article ...

Deficiency cited, complaint : C. An administrator shall ensure that a resident's medical record contains: 9. Orders;

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. 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 ...

Deficiency cited, complaint : 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 ...

Based on documentation review, record review, and interview, the administrator failed 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. 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 ...

Deficiency cited, complaint : C. If a behavioral health residential facility provides assistance in the self-administration of medication, an administrator shall ensure that: 6. Assistance ...

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. 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 ...

Deficiency cited, complaint : A. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 1. The ...

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. 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 ...

Deficiency cited, complaint : 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 ...

Based on documentation review and interview, the administrator failed to ensure if an administrator had a reasonable basis, according to A.R.S. § 46-454, 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 took immediate action to stop the suspected abuse; reported the suspected abuse of the resident according to A.R.S. § 46-454; documented the suspected abuse, any action taken according to subsection (I)(1), and the report in subsection (I)(2); maintained the documentation in subsection (I)(3) for at least 12 months after the date of the report in subsection (I)(2); initiated an investigation of the suspected abuse, neglect, or exploitation and documented the following information within five working days after the report required in (I)(2): a. The dates, times, and description of the suspected abuse; b. 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; c. The names of witnesses to the suspected abuse; and, d. The actions taken by the administrator to prevent the suspected abuse from occurring in the future; and 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. The deficient ...

Deficiency cited, complaint : 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 ...

Based on observation, documentation review, and interview, the administrator failed to ensure there was a daily staffing schedule to indicate the name of each employee assigned to work, including on-call personnel members. The deficient practice posed a risk as there was no record to ensure a current behavioral health professional was on-call. 1. The Compliance Officer observed E1 working at the facility at the time of the inspection. 2. A review of facility documentation revealed daily staffing schedules for August 2024. The facilities schedule provided by E1 revealed on Monday, August 19, 2024, and Monday August 26, 2024, no staff were documented as working 8:00 AM to 2:00 PM. The schedule reflected August 27, 2024, E1 was working as "PRN" with no hours identified. 3. In an interview, E1 reported there were no children at the home during the hours identified. E1 reported E1 was on call and available to come to the facility if needed. E1 acknowledged the staffing schedule did not reflect coverage on the date and hours identified.

Deficiency cited, complaint : 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 ...

Based on record review and interview, the 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. 1. A review of R1's and R2's medical records revealed behavioral health assessments completed within the last twelve months from a behavioral health provider other than BH6115. However, documentation of a review and update of R1's and R2's assessment information was not available for review. 2. In an interview, E1 reported R1 and R2's behavioral health assessments were reviewed by the facility BHP. E1 reported E1 was unaware the review was required to be documented after the review was completed. E1 acknowledged the 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.

Deficiency cited, complaint : 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 ...

Based on record review and interview, the administrator failed to ensure a treatment plan was developed and implemented for each resident to include the signature of the resident or the resident's representative, and the date signed, or documentation of the refusal to sign, for four of four residents sampled. The deficient practice posed a risk if the treatment plan was not developed to articulate decisions and agreements. 1. A review of R1's medical record revealed a treatment plan dated in August 2024. The treatment plan included the minor residents name and signature. 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 two treatment plans dated in July 2024. The treatment plans included the minor residents name and signature. The treatment plans did not include the signature of the resident's representative, and the date signed, or documentation of the refusal to sign. 3. A review of R3's medical record revealed a treatment plan dated in August 2024. The treatment plan did not include the signature of the resident's representative, and the date signed, or documentation of the refusal to sign. 4. A review of R4's medical record revealed a treatment plan dated in April 2024. The treatment plan included the minor residents name and signature. The treatment plans did not include the signature of the resident's representative, and the date ...

Deficiency cited, complaint : A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that: 4. Includes: f. The signature of the personnel ...

Based on record review and interview, the administrator failed to ensure a treatment plan was developed and implemented for each resident to include the signature of the personnel member who developed the treatment plan and the date signed. 1. A review of R1's medical record revealed a treatment plan dated August 2, 2024. The treatment plan reflected "Treatment Plan Facilitation by: [E5] with no signature and a typed date of "5/22/24."The treatment plan was signed by E1 and E6 however there was no date signed. 2. A review of R3's medical record revealed a treatment plan dated August 2, 2024. The treatment plan reflected "Treatment Plan Facilitation by: [E5] with no signature and a typed date of "5/22/24."The treatment plan was signed by E1 however there was no date signed. The treatment plan included a signature of E6 with a typed date of August 13, 2024. 3. In an interview, E1 reported E1 created R1 and R3's treatment plans and the reflection of E5 creating the treatment plans was a documentation error. E1 reported the treatment plan creation date's reflected on the treatment plans may also be a documentation error as E1 emailed the treatment plans to the BHP after their completion for a signature and review. E1 acknowleged the administrator failed to ensure a treatment plan was fully developed and implemented for each resident to include the signature of the personnel member who developed the treatment plan and the date signed.

Deficiency cited, complaint : 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 ...

Based on record review and interview, the administrator failed to ensure a treatment plan was developed and implemented for each resident that, if completed by a behavioral health technician (BHT), was reviewed and signed by a behavioral health professional (BHP) within 24 hours after the completion of the treatment plan to ensure the treatment plan was complete and accurate and met the resident's treatment needs. 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. 1. A review of R1's medical record revealed a treatment plan dated August 2, 2024. The treatment plan included a signature of E1 and E6 however there was no date attached to the signatures. 2. A review of R2's medical record revealed a treatment plan dated July 23, 2024 signed as created by a BHT, E2 on July 23, 2024. However, the treatment plan revealed the BHP reviewed the treatment plan on July 29, 2024. The treatment plan did not include a documented review by the BHP within 24 hours. 3. A review of R3's medical record revealed a treatment plan dated August 2, 2024. The treatment plan was signed by E1 however there was no date signed. The treatment plan included a signature of E6 with a typed date of August 13, 2024. The treatment plan did not include a documented review by the BHP within 24 hours. 4. A review of R4's medical record revealed a treatment plan ...

Deficiency cited, complaint : 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. ...

Based on record review and interview, the administrator failed to ensure a treatment plan was developed and implemented for each resident and was reviewed and updated on an on-going basis according to the review date specified in the treatment plan, for one of four 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. 1. A review of R2's medical record revealed a treatment plan dated July 23, 2024. The treatment plan identified a review date of "August 19, 2024." No updated treatment plans for R2 were available for review. 2. A review of R4's medical record revealed a treatment plan dated April 24, 2024 . The treatment plan identified a review date of "May 22, 2024." No updated treatment plans for R4 were available for review. 3. In an interview, E1 acknowledged the treatment plans identified were the most current treatment plans for R2 and R4. E1 acknowledged R2's and R4's treatment plans were not reviewed and updated according to the review date specified in the treatment plan.

Deficiency cited, complaint and compliance (annual) : 36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition A. Each health care institution shall develop and ...

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 continued competency training. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not developed and implemented. 1. A review of facility documentation revealed a policy and procedure titled "Fall Prevention and Fall Recovery" (dated May 25, 2023). However, the training program did not include initial training and continued competency training in fall prevention and fall recovery. 2. A review of E2's, E3's, E6's, and E7's personnel records revealed initial training in fall prevention and fall recovery was not available for review. 3. A review of E1's and E5's personnel records revealed continued competency training in fall prevention and fall recovery was not available for review. 4. In an interview, E5 acknowledged a training program for all staff regarding fall prevention and fall recovery to include continued competency training was not developed and administered. This is a repeat deficiency from the on-site compliance inspection conducted on June 19, 2023.

Deficiency cited, complaint and compliance (annual) : C. An administrator shall ensure that: 5. Unless otherwise stated: a. Documentation required by this Article is provided to the Department within two hours ...

Based on record review and interview, the administrator failed to ensure documentation required by Article 7 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 compliance. 1. A review of R3's (admitted in 2024) medical record revealed a treatment plan (dated in 2024). The treatment plan stated "1 hr wkly group." 2. A review of R3's (admitted in 2024) medical record revealed treatment plan (dated in 2024). The treatment plan revealed R3 received assistance in the self-administration of medication. 3. A review of R4's (admitted in 2023) medical record revealed a treatment plan (dated in 2024). The treatment plan stated "1 hr wkly group." 4. The Compliance Officer requested, on June 5, 2024 at 8:37AM and at 11:35AM, R3's documentation of group counseling sessions for May 2024. However, documentation of R3's group counseling sessions for May 2024 was not provided for review within two hours after a Department request. 5. The Compliance Officer requested, on June 5, 2024 at 8:37AM, R3's documentation of medication orders. However, documentation of R3's medication orders was not provided for review within two hours after a Department request. 6. The Compliance Officer requested, on June 5, 2024 at 8:37AM and at 11:35AM, R4's documentation of group counseling sessions for May 2024. However, documentation of R4's group counseling sessions for May 2024 was not provided for review ...

Deficiency cited, complaint and compliance (annual) : K. An administrator shall: 7. If a resident's absence is unauthorized as determined according to the criteria in subsection (K)(6), within an hour after ...

Based on record review and interview, the administrator failed to ensure if a resident's absence was unauthorized, the resident's parent or legal guardian was notified within an hour after determining the resident's absence was unauthorized. The deficient practice posed a risk as the resident was a minor. 1. A review of R1's medical record revealed a document titled "Angel's Safe Haven Incident Report" (dated May 31, 2024 at 12:45AM). The report stated "Staff was making rounds for the nightly 15min bed checks upon checking staff saw beds empty. After noticing [R1] was gone was able to see bedroom window was left open & appeared client had snuck out the window." The report revealed the Department of Child Safety was notified on May 31, 2024 at 1:00PM; and R1's parent or legal guardian was notified. However, the time R1's parent or legal guardian was notified was not available for review. 2. In an interview, E5 reported R1's parent or legal guardian was notified immediately after R1's unauthorized absence, however, E5 did not know if this information was documented.

Deficiency cited, complaint and compliance (annual) : An administrator shall ensure that: 2. Documentation of current contracted services is maintained that includes a description of the contracted services ...

Based on record review and interview, the administrator failed to ensure documentation of current contracted services was maintained, for one contracted behavioral health professional (BHP). 1. A review of E2's (hired in 2024) personnel record revealed E2 was hired as the BHP. However, E2's personnel record revealed current documentation of contracted services was not available for review. 2. In an interview, E5 was unable to locate documentation of current contracted services for E2, and acknowledged documentation of current contracted services was not maintained for E2.

Deficiency cited, complaint and compliance (annual) : B. An administrator shall ensure that: 2. A personnel member's skills and knowledge are verified and documented: a. Before the personnel member provides ...

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 two of eight personnel members sampled. The deficient practice posed a risk to the health and safety of residents if a personnel member was not qualified to provide behavioral health services. 1. A review of E7's personnel record revealed documentation to demonstrate skills and knowledge were verified before E7 provided behavioral health services was not available for review. 2. A review of R3's medical record revealed a medication administration record (MAR) for May 2024. The MAR revealed E7 provided assistance in the self-administration of medication to R3. 3. A review of E8's personnel record revealed documentation to demonstrate skills and knowledge were verified before E8 provided behavioral health services was not available for review. 4. A review of R3's medical record revealed a MAR for May 2024. The MAR revealed E8 provided assistance in the self-administration of medication to R3. 5. In an interview, E5 reported E5 did not know if E7's and E8's skills and knowledge were verified and documented. E5 acknowledged the documentation was not available for review.

Deficiency cited, complaint and compliance (annual) : B. An administrator shall ensure that: 3. Sufficient personnel members are present on a behavioral health residential facility's premises with the ...

Based on 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 ensure the health and safety of a resident. The deficient practice posed a risk if personnel members were unable to meet a resident's needs, or were a danger to a vulnerable population. 1. A review of facility documentation revealed a policy and procedure titled "Staffing of Residential Facilities - Employees" (dated May 25, 2023). The policy and procedure stated " ... 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 facility documentation revealed a daily staffing schedule for June 2024. The schedule revealed E6 was scheduled to work alone on the following dates and the following times: -June 6, 2024 from 11:00PM to 7:00AM; -June 5-6, 2024 from 11:00PM to 8:00AM; and -June 7-8, 2024 from 11:00PM to 9:00PM. 3. A review of facility documentation revealed daily staffing schedules for May 2024 and June 2024. The schedule revealed E7 was scheduled to work alone on the following dates and the following times: -May 27, 2024 from 3:00PM to 11:00PM; -May 29, 2024 from 3:00PM to 11:00PM; -May 31, 2024 from 3:00PM to ...

Deficiency cited, complaint and compliance (annual) : 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 ...

Based on documentation review, record review, and interview, the administrator failed to ensure a personnel member provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for four of eight personnel members sampled. The deficient practice posed a potential TB exposure risk to residents. Arizona Administrative Code (A.A.C.) 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: 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, baseline 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). A.A.C. R9-10-113(B)(1)(a)(i) A health care institution's chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious ...

Deficiency cited, complaint and compliance (annual) : G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes: 3. ...

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 education and experience applicable to the individual's job duties, for one of four behavioral health technicians (BHT) sampled. 1. A review of facility documentation revealed a policy and procedure titled "Job Descriptions" (dated May 25, 2023). The policy and procedure stated " ... Each staff member will have a written job description listing the duties for that position ... Behavioral Health Technician See attached job description ... Behavioral Health Technician ... Minimal Qualifications: Bachelor's degree in behavioral health or health related field or a bachelor's degree in any field with two years' work experience in behavioral health service delivery; or a high school diploma, or general equivalency diploma (FED) or, Job Corp diploma\ certifying completion of academic studies and a combination of behavioral health education and experience working with adolescent youth within a mental health agency totaling a minimum of four years." 2. A review of facility documentation revealed a policy and procedure titled "Job Descriptions" (dated May 25, 2023). The policy and procedure stated " ... Each staff member will have a written job description listing the duties for that position ... Behavioral Health Technician See attached job description ... Behavioral Health Technician ...

Deficiency cited, complaint and compliance (annual) : G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes: 3. ...

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 Arizona Revised Statutes (A.R.S.) §§ 36-425.03(A), for one of eight personnel records sampled, and A.R.S. §§ 36-425.03(E)(G), for three of eight personnel records sampled. The deficient practice posed a risk if E6, E7, and E8 were a danger to a vulnerable population. A.R.S. §§ 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." A.R.S. §§ 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. §§ 36-425.03(G) states "Employers of children's behavioral health program personnel shall make documented ...

Deficiency cited, complaint and compliance (annual) : G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes: 3. ...

Based on documentation review, record review, and interview, the administrator failed to ensure a personnel record is maintained for each personnel member included 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, for two of eight personnel members sampled. The deficient practice posed a risk if E6 and E7 were unable to meet a resident's needs during an emergency or during an accident. 1. A review of facility documentation revealed a policy and procedure titled "Staffing of Residential Facilities - Employees" (dated May 25, 2023). The policy and procedure stated " ... 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 facility documentation revealed a daily staffing schedule for June 2024. The schedule revealed E6 was scheduled to work alone on the following dates and the following times: -June 6, 2024 from 11:00PM to 7:00AM; -June 5-6, 2024 from 11:00PM to 8:00AM; and -June 7-8, 2024 from 11:00PM to 9:00PM. 3. A review of facility documentation revealed daily staffing schedules for May 2024 and June 2024. The schedule revealed E7 was scheduled to work alone on the following dates and ...

Deficiency cited, complaint and compliance (annual) : J. An administrator shall ensure that the following personnel members have first-aid and cardiopulmonary resuscitation training specific to the populations ...

Based on documentation review, 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 of the behavioral health residential facility who had first-aid and cardiopulmonary resuscitation (CPR) training specific to the populations served by the behavioral health residential facility. The deficient practice posed a risk as E6 and E7 worked alone and did not have first-aid and CPR training. 1. A review of facility documentation revealed a daily staffing schedule for June 2024. The schedule revealed E6 was scheduled to work alone on the following dates and the following times: -June 6, 2024 from 11:00PM to 7:00AM; -June 5-6, 2024 from 11:00PM to 8:00AM; and -June 7-8, 2024 from 11:00PM to 9:00PM. 2. A review of facility documentation revealed daily staffing schedules for May 2024 and June 2024. The schedule revealed E7 was scheduled to work alone on the following dates and the following times: -May 27, 2024 from 3:00PM to 11:00PM; -May 29, 2024 from 3:00PM to 11:00PM; -May 31, 2024 from 3:00PM to 11:00PM; -June 2, 2024 from 9:00AM to 4:00PM; and -June 3, 2024 from 2:00PM to 11:00PM. 3. A review of E6's (hired in 2024) personnel record revealed E6 was hired as a behavioral health technician (BHT). However, documentation of first-aid and CPR training was not available for review. 4. A review of E7's (hired in 2024) personnel record revealed E7 was hired as a ...

Deficiency cited, complaint and compliance (annual) : 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. ...

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 three of four residents sampled. The deficient practice posed a potential TB exposure risk to residents. Arizona Administrative Code (A.A.C.) 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: 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, baseline 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). 1. A review of R1's (admitted in 2024) medical record revealed documentation of a Mantoux TB skin test. However, documentation of baseline screening consisting of assessing risks of prior exposure to infectious TB and determining if ...

Deficiency cited, complaint and compliance (annual) : 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 ...

Based on record review and interview, the administrator failed to ensure a treatment plan completed by a behavioral health technician (BHT), was reviewed and signed by a behavioral health professional (BHP) within 24 hours after the completion of the treatment plan, for four of four residents 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. 1. A review of R1's (admitted in 2024) medical record revealed a treatment plan (dated in 2024) completed by a BHT. However, the document was not reviewed and signed by a BHP. 2. A review of R2's (admitted in 2023) medical record revealed a treatment plan (dated in 2024) completed by a BHT. However, the document was not reviewed and signed by a BHP. 3. A review of R3's (admitted in 2024) medical record revealed a treatment plan (dated in 2024) completed by a BHT. However, the document was not reviewed and signed by a BHP. 4. A review of R4's (admitted in 2023) medical record revealed a treatment plan (dated in 2024) completed by a BHT. However, the document was not reviewed and signed by a BHP. 5. In an interview, E5 reported E9 reviewed the treatment plans during staffing meetings. 6. In an interview, E5 acknowledged the BHP did not review and sign R1's, R2's, R3's, and R4's treatment plans within 24 hours after a BHT completed the treatment plan.

Deficiency cited, complaint and compliance (annual) : G. An administrator shall ensure that a discharge summary for a resident: 2. Includes: a. The following information authenticated by a medical practitioner or ...

Based on record review and interview, the administrator failed to ensure a discharge summary for a resident, to include the requirements in R9-10-709(G)(2)(a)(i)(ii)(iii), was authenticated by a medical practitioner or behavioral health professional (BHP), for one of two discharged residents sampled. The deficient practice posed a risk as a review of services was not established by the required individual. 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 R2's medical record revealed a discharge summary (dated May 2024). The summary stated " ... Completed [R2's] treatment goals at a high 85%." The summary included the requirements in R9-10-709(G)(2)(a)(i)(ii)(iii). However, the summary was not authenticated by a medical practitioner or BHP. 2. In an interview, E5 reported discharge summaries were usually signed by a medical practitioner or BHP. E5 acknowledged R2's discharge summary was not authenticated by a medical practitioner or BHP.

Deficiency cited, complaint and compliance (annual) : C. An administrator shall ensure that a resident's medical record contains: 9. Orders;

Based on documentation review, record review, observation, and interview, the administrator failed to ensure a resident's medical record contained medication orders, for one of four 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. 1. A review of R3's (admitted in 2024) medical record revealed treatment plan (dated in 2024). The treatment plan revealed R3 received assistance in the self-administration of medication. 2. A review of R3's medical record revealed medication orders (dated February 1, 2024) for the following medications: -"Quetiapine 100mg tablet take 1 tablet by oral route 2 times every;" and -"Sertraline 25mg tablet take 1 tablet by oral route every day." 3. A review of R3's medical record revealed a medication administration record (MAR) for May 2024. The MAR documented R3 received assistance in the self-administration of medication on the following dates: -"Quetiapine 25mg 1 tab every evening:" May 1-8, 2024; -"Quetiapine 50mg 1 tab every evening:" May 9-31, 2024; and -"Seroquel 50mg 1 tab every morning:" May 1-31, 2024. However, medication orders for the aforementioned medications were not available for review. 4. The Compliance Officer observed a medication container labeled for R3. The label stated "Quetiapine Fumarate 50mg tab Take 1 tablet by mouth every day at 8 pm." However, a medication order for Quetiapine Fumarate 50mg every day ...

Deficiency cited, complaint and compliance (annual) : C. An administrator shall ensure that a resident's medical record contains: 15. Documentation of behavioral health services and physical health services ...

Based on record review and interview, the administrator failed to ensure a resident's medical record contained documentation of behavioral health services provided to the resident, for two of two current 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. 1. A review of R3's (admitted in 2024) medical record revealed a treatment plan (dated in 2024). The treatment plan stated "1 hr wkly group." 2. The Compliance Officer requested, on June 5, 2024 at 8:37AM and at 11:35AM, R3's complete medical record to include documentation of group counseling sessions for May 2024. However, documentation of R3's group counseling sessions for May 2024 was not available for review. 3. A review of R4's (admitted in 2023) medical record revealed a treatment plan (dated in 2024). The treatment plan stated "1 hr wkly group." 4. The Compliance Officer requested, on June 5, 2024 at 8:37AM and at 11:35AM, R4's complete medical record to include documentation of group counseling sessions for May 2024. However, documentation of R4's group counseling sessions for May 2024 was not available for review. 5. In an interview, E5 reported R3 and R4 received group counseling once a week for an hour, however, this documentation was not available. 6. In an interview, E5 acknowledged R3's and R4's medical records were not maintained to contain documentation of behavioral health ...

Deficiency cited, complaint and compliance (annual) : A. An administrator shall ensure that: 2. If a behavioral health residential facility is licensed to provide behavioral health services to individuals whose ...

Based on documentation review, record review, and interview, the administrator failed to ensure, if a behavioral health residential facility was 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 health and safety risk to residents, under the age of 18, who required continuous protective oversight. 1. A review of Department documentation revealed BH6115 was licensed to provide behavioral health services to individuals whose behavioral health issue limits the individuals' ability to function independently (individuals under 18 years of age). 2. A review of facility documentation revealed a daily staffing schedule for May 2024. The staffing schedule revealed the facility maintained three shifts with one personnel member generally scheduled per shift. 3. A review of R1's (admitted in 2024) medical record revealed a document titled "Angel's Safe Haven Incident Report" (dated May 28, 2024 at 12:45PM). The report stated " ... Client refused and went to [R1's] room to 'chill out' ... Staff called the house manager ... While on the phone ... staff went outside to check on the other residents who were throwing around a football. When the staff came back inside the front door closed. Another resident ...

Deficiency cited, complaint and compliance (annual) : C. If a behavioral health residential facility provides assistance in the self-administration of medication, an administrator shall ensure that: 4. Training ...

Based on record review and interview, the administrator failed to ensure training for a personnel member, other than a medical practitioner or registered nurse, in assistance in the self-administration of medication was provided by a medical practitioner or registered nurse or an individual trained by a medical practitioner or registered nurse, for one of four behavioral health technicians (BHTs) sampled. The deficient practice posed a risk if a resident experienced a change in condition due to improper assistance in the self-administration of medication. 1. A review of E7's (hired in 2024) personnel record revealed E7 was hired as a BHT. The personnel record revealed documentation of training in assistance in the self-administration of medication. However, the training in assistance in the self-administration of medication was not provided by a medical practitioner or registered nurse or an individual trained by a medical practitioner or registered nurse. 2. A review of R3's medical record revealed a medication administration record (MAR) for May 2024. The MAR revealed E7 provided assistance in the self-administration of medication to R3. 3. In an interview, E5 reported the registered nurse, E3, has all the documentation of training in assistance in the self-administration of medication. E5 acknowledged training for a personnel member, other than a medical practitioner or registered nurse, in assistance in the self-administration of medication was provided by a medical ...

Deficiency cited, complaint and compliance (annual) : C. If a behavioral health residential facility provides assistance in the self-administration of medication, an administrator shall ensure that: 6. Assistance ...

Based on documentation review, 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 four 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. 1. A review of R3's (admitted in 2024) medical record revealed treatment plan (dated in 2024). The treatment plan revealed R3 received assistance in the self-administration of medication. 2. A review of R3's medical record revealed medication orders (dated February 1, 2024) for the following medications: -"Quetiapine 100mg tablet take 1 tablet by oral route 2 times every;" and -"Sertraline 25mg tablet take 1 tablet by oral route every day." 3. A review of R3's medical record revealed a medication administration record (MAR) for May 2024. The MAR documented R3 received assistance in the self-administration of medication on the following dates: -"Quetiapine 25mg 1 tab every evening:" May 1-8, 2024; -"Quetiapine 50mg 1 tab every evening:" May 9-31, 2024; and -"Seroquel 50mg 1 tab every morning:" May 1-31, 2024. However, medication orders for the aforementioned medications were not available for review. 4. The Compliance Officer observed medication container labeled for R3. The label stated "Quetiapine Fumarate 50mg tab Take 1 tablet by mouth every day at 8 pm." However, a ...

Deficiency cited, complaint and compliance (annual) : A. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 1. The ...

Based on observation and interview, the administrator failed to ensure the premises was cleaned. 1. The Compliance Officer observed one bathroom accessible from a common area. 2. The Compliance Officer observed a what appeared to be rust near the shower faucet along the tub. 3. The Compliance Officer observed a discolored shower curtain. 4. In an interview, E5 acknowledged the common bathroom was not cleaned.

Deficiency cited, complaint and compliance (annual) : B. An administrator shall ensure that: 2. At least one bathroom is accessible from a common area that: c. Contains the following: iii. Toilet tissue for each ...

Based on observation and interview, the administrator failed to ensure at least one bathroom accessible from a common area contained toilet tissue for each toilet. The deficient practice posed an infection control risk. 1. The Compliance Officer observed one bathroom accessible from a common area. However, the bathroom did not contain toilet tissue for each toilet. 2. In an interview, E5 acknowledged the common bathroom did not contain contain toilet tissue for each toilet.

Deficiency cited, complaint and compliance (annual) : B. An administrator shall ensure that: 2. At least one bathroom is accessible from a common area that: c. Contains the following: v. Paper towels in a ...

Based on observation and interview, the administrator failed to ensure at least one bathroom accessible from a common area contained paper towels in a dispenser or a mechanical air hand dryer. The deficient practice posed an infection control risk. 1. The Compliance Officer observed one bathroom accessible from a common area. However, the bathroom did not contain paper towels in a dispenser or a mechanical air hand dryer. 2. In an interview, E5 acknowledged the common bathroom did not contain paper towels in a dispenser or a mechanical air hand dryer.

Deficiency cited, compliance (annual) : A.R.S.§ 36-411. Residential care institutions; nursing care institutions; home health agencies; fingerprinting requirements; exemptions; definitions A. Except ...

Based on record review, documentation review and interview, the residential care institution failed to ensure compliance with A.R.S. § 36-411(A), for one of six personnel members sampled. The deficient practice posed a risk if E6 was a danger to a vulnerable population. 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.

Deficiency cited, compliance (annual) : 36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition A. Each health care institution shall develop and ...

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. 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.

Deficiency cited, compliance (annual) : 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 ...

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

Deficiency cited, compliance (annual) : G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes: 3. ...

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. 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.

Deficiency cited, compliance (annual) : J. An administrator shall ensure that the following personnel members have first-aid and cardiopulmonary resuscitation training specific to the populations ...

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. 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 ...

Deficiency cited, compliance (annual) : A. An administrator shall ensure that: 6. Except as provided in subsection (E)(1)(a), a medical practitioner performs a medical history and physical ...

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. 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.

Deficiency cited, compliance (annual) : A. An administrator shall ensure that: 8. If a behavioral health assessment is conducted by a: a. Behavioral health technician or registered nurse, within 24 ...

Based on record review and interview, the administrator failed to ensure a behavioral health assessment conducted by a behavioral health technician (BHT) was reviewed and signed by the behavioral health professional (BHP) within 24 hours, for one of two residents sampled. 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.

Deficiency cited, compliance (annual) : 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. ...

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.

Deficiency cited, compliance (annual) : B. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 2. The ...

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 plan reinforces and clarifies standards expected of employees. 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.

Deficiency cited, compliance (annual) : B. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 4. A disaster ...

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. The deficient practice posed a risk if employees were unable to implement a disaster plan. 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.

Deficiency cited, compliance (annual) : B. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 5. An ...

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, and the Department was unable to determine substantial compliance during the inspection. 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 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.

Deficiency cited, compliance (annual) : A. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 10. Hot water ...

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. 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.