Dalia Homecare LLC – Children’s Residential Facility

Deficiency cited, complaint : R9-10-703.C.1.f. Administration C. An administrator shall ensure that: 1. Policies and procedures are established, documented, and implemented to protect the ...

Based on documentation review, record review, and interview, the administrator failed to ensure policies and procedures were implemented to protect the health and safety of a resident that covered implementation of the requirements in A.R.S. § 36-411. The deficient practice posed a risk if E5 were around a vulnerable population. 1. A review of the facility documentation revealed a job description for the administrator and behavioral health technician. The job description stated, " ... the qualifications for an Administrator and Behavioral Health Technician... Fingerprint Clearance Card (Will be checked once a month for Validity) ... Fingerprint validity will be checked once a month by program director and if an employee’s card is found to be invalid they will be removed from the schedule immediately until further notice." 2. A review of E5's personnel record revealed E5 is the facility administrator. E5's personnel record revealed fingerprint clearance card documentation; however, a review of the Department of Public Safety's website revealed the status of E5's fingerprint clearance card was "Not Valid." E5's personnel record revealed E5 had applied for a good cause exemption on March 27, 2026. On April 24, 2026, E5 received a notice from the Arizona Board of Fingerprinting stating, "You recently submitted items for your application. However, your application is still incomplete." The document reflected that the application was missing Police and Court documentation for ...

Deficiency cited, complaint : R9-10-706.E.2. Personnel E. An administrator shall ensure that: 2. A personnel member completes orientation before providing behavioral health services or ...

Based on documentation review, record review, and interview, the administrator failed to ensure that a personnel member completed orientation before providing behavioral health services or physical health services. The deficient practice posed a risk, as services were provided prior to receiving documented orientation to the residents' needs. 1. A review of E8's personnel record revealed E8 was hired on April 1, 2026, as a counselor. A review of E8's personnel record revealed the facility completed orientation with E8 on August 7, 2026. 2. A review of R2's medical record revealed R2 received behavioral health counseling from E8 prior to E8 receiving orientation on August 7, 2026. 3. In a phone interview, E6 reported E6 is the facility's primary behavioral health professional. E6 reported E8 provides counseling and on-site support to the facility when E6 is unavailable in a behavioral health professional capacity. 4. In a phone interview, E9 reported E9 completed orientation with E8 following information received at previous inspections. E9 acknowledged the administrator failed to complete orientation with E8 before E8 provided behavioral health services.

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 record review and interview, the administrator failed to ensure that a treatment plan was developed and implemented for each resident and was reviewed and updated on an ongoing basis when a resident had a significant change in condition or experienced an event that affected treatment. The deficient practice posed a risk, as the resident's treatment needs did not reflect a significant event. 1. A review of R1's medical record revealed an incident report dated July 24, 2026. The incident report stated, "....After getting upset about lunch [E1] went to [E1] room and started to bite self then grabbed a fork and talked about killing self ..." 2. A review of R1's medical record revealed a treatment plan dated July 13, 2026. The treatment plan revealed no history of self-harm. A review of R1's medical record revealed no additional treatment plans available for review. A review of R1's medical record revealed R1's treatment plan was not updated following the incident on July 24, 2026, where R1 reflected thoughts of self-harm. 3. In an interview, E1 reported that R1's medical record reflected that R1's treatment plan was not updated following the incident on July 24, 2026, during which R1 had an experience that affected R1's treatment needs.

Deficiency cited, complaint : R9-10-722.B.8.k. Physical Plant Standards B. An administrator shall ensure that: 8. A resident bedroom complies with the following: k. Has a clothing rod or ...

Based on onbservation and interview, th e administrator failed to ensure that a resident bedroom had a clothing rod or hook in the bedroom designed to minimize the opportunity for a resident to cause self-injury. The deficient practice posed a risk as the resident in the identified room may have had a history of self-harm. 1. During a facility tour with E1, the Compliance Officer and E1 observed metal hooks in R1 and additional resident's bedrooms. The hooks observed did not minimize the opportunity for a resident to cause self-injury. 2. A review of R1's medical record revealed an incident report dated July 24, 2026. The incident report revealed R1 expressed thoughts of self-harm. 3. In an interview, E1 reported no knowledge that the hooks were present and were not designed to minimize self-injury. E1 contacted the facility maintenance staff during the inspection to have the hooks removed.

Deficiency cited, complaint and compliance (annual) : R9-10-703.A.3. Administration A. A governing authority shall: 3. Designate, in writing, an administrator who has the qualifications established in subsection ...

Based on documentation review and interview, the governing authority failed to designate, in writing, the administrator who had the qualifications established in policies and procedures. The deficient practice posed a risk as the identified Administrator has an invalid fingerprint clearance card. 1. A review of facility documentation revealed a policy titled, "Qualification of Specific Positions or Tasks." The policy stated, "Administrator: Responsible for documentation and all files. Also, any agency complaints or quality of care concerns... Qualifications: Fingerprint card and experience in the behavioral health field of at least 2 years." 2. A review of facility documentation revealed a policy titled, "Staff Management and Staff Records." The policy stated, "Also, Fingerprint validity will be checked once a month by program director and if an employee's card is found to be invalid they will be removed from the schedule immediately until further notice." 3. A review of the Department of Public Safety Website revealed E2's fingerprint clearance card was "Not Valid" at the time of the inspection. 4. In an interview, E2 reported E2 is the Administrator. E2 acknowledged that E2 was aware E2's fingerprint clearance card was not valid. 5. In an exit interview with E3, the findings were reviewed with no additional information to add.

Deficiency cited, complaint and compliance (annual) : R9-10-703.B.3. Administration B. An administrator: 3. Except as provided in subsection (A)(6), designates, in writing, an individual who is present on the ...

Based on documentation review and interview, the administrator failed to designate in writing an individual who was present on the behavioral health residential facility's premises and accountable for the behavioral health residential facility when the administrator was not present on the behavioral health residential facility's premises. The deficient practice posed a risk as no individual representative of the facility was identified as accountable at the time of the inspection. 1. The Compliance Officer requested to review documentation reflecting an individual who was present on the behavioral health residential facility's premises and accountable for the behavioral health residential facility when the administrator was not present on the behavioral health residential facility's premises. However, there was no documentation provided. 2. In an interview, E1 reported no knowledge of an individual who was present on the behavioral health residential facility's premises and accountable for the behavioral health residential facility when the administrator was not present on the behavioral health residential facility's premises. E1 reported there was no documentation for review to reflect this identification. 3. In an interview, E9 reported E2 is the Administrator and E10 is designated in charge when E2 is not present. E9 reported E9 was not a designee and was a "BHT." 4. In an exit interview, E3 reported no knowledge of an individual who was present on the behavioral health ...

Deficiency cited, complaint and compliance (annual) : R9-10-703.C.1.f. Administration C. An administrator shall ensure that: 1. Policies and procedures are established, documented, and implemented to protect the ...

Based on documentation review, record review, and interview the administrator failed to ensure policies and procedures were implemented to protect the health and safety of a resident that covered implementation of the requirements in A.R.S. §§ 36-411, 36-411.01, and 36-425.03, as applicable. The deficient practice posed a risk as E2 and E3 were around a vulnerable population. 1. A review of the facility documentation revealed a job description for the Administrator and Behavioral Health Technician. The job description stated, "the qualifications for an Administrator and Behavioral Health Technician... Fingerprint Clearance Card (Will be checked once a month for Validity).. Fingerprint validity will be checked once a month by program director and if an employee’s card is found to be invalid they will be removed from the schedule immediately until further notice." 2. A review of E2's personnel record revealed E2 is the facility administrator. E2's personnel record revealed fingerprint clearance card documentation. The status of the fingerprint clearance card was "Not Valid." E2's personnel record revealed E2 had applied for a good cause exemption on March 27, 2026. On April 24, 2026, E2 received a notice from the Arizona Board of Fingerprinting stating, "You recently submitted items for your application. However, your application is still incomplete." The document reflected that the application was missing Police and Court documentation for "09/17/2025: Tempe, AZ ...

Deficiency cited, complaint and compliance (annual) : R9-10-703.C.5.a-b. Administration C. An administrator shall ensure that: 5. Unless otherwise stated: a. Documentation required by this Article is provided to ...

Based on documentation review, record review, and interview, the administrator failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request. The deficient practice posed a risk if the behavioral health residential facility was not maintaining documents and records in a manner that ensures continuity of care. A review of the facility's policies and procedures revealed a policy titled, "Record Keeping Procedures and Confidentiality." The policy stated, "The CEO through the Program Manager shall ensure that client records are maintained as follows: In a central location within the agency and available for inspection by the Department." The policy and procedure manual additionally stated, "Facility policies have been revised to explicitly state that licensure constitutes consent to entry and inspection by ADHS... Mandatory inspection compliance training has been implemented for all administrative and supervisory staff... The Administrator will conduct quarterly reviews to confirm inspection readiness and adherence to inspection cooperation requirements." The Compliance Officer requested to review policies and procedures, all personnel records, all medical records and facility documentation at approximately 1:00 PM. The Compliance Officer received various documents from approximately 1:00 PM to 7:00 PM. In an interview, E3 reported having difficulty accessing medical records. E3 also reported not having the ...

Deficiency cited, complaint and compliance (annual) : R9-10-703.G.2. Administration G. An administrator shall provide written notification to the Department of a resident's: 2. Self-injury, within two working days ...

Based on documentation review, record review, and interview, the administrator failed to provide written notification to the Department of a resident's self-injury within two working days after the resident inflicted a self-injury or had an accident that required immediate intervention by an emergency medical services provider. The deficient practice posed a risk as the Department was unable to assess if there was an immediate health and safety concern for the residents residing in the behavioral health residential facility. 1. A review of facility documentation revealed a policy titled, "Investigation of Child Maltreatment." The policy stated, "**NOTE: Call the CPS Hotline EVERY TIME there is suspected abuse, neglect, and exploitation... In the case that there are any alleged or suspected incidents of child maltreatment, Dalia Homecare is entitled to report such allegations to local law enforcement or Child Protective Services as required by A.R.S. 13-3620. All staff is required to report any allegations to the corporate administration team. Arizona’s licensing authorities and the child’s placing agency or person will be notified as well. Precautionary measures will be taken to prevent further risk to the child who allegedly suffered the maltreatment and potential risk to other children in care. These measures will include removal from the preying member(s). Any staff that committed or allowed child maltreatment will be immediately taken off the schedule and evaluated for ...

Deficiency cited, complaint and compliance (annual) : R9-10-706.B.2.a. Personnel B. An administrator shall ensure that: 2. A personnel member's skills and knowledge are verified and documented: a. Before the ...

Based on documentation review, record review, and interview, the administrator failed to ensure a personnel member's skills and knowledge were verified and documented before the personnel member provided physical health services or behavioral health services. The deficient practice posed a direct risk if the personnel members did not have the knowledge or ability to safely deliver behavioral health services to the specific population within the behavioral health residential facility. A review of the facility's policies and procedures revealed a policy titled, "Qualifications of Specific Positions or Tasks," which stated, "Program Director... Skills and Knowledge: Critical thinking skills and knowledge of children whom may have a behavioral health diagnosis. The ability to be a team player and meticulous with notations, keeping records as well keeping a clean environment. An all-around renaissance person, with the compassion of a teach (sic) but also the conciseness to make decisions like a fire fighter." Additionally stated, "BHT... Skills and Knowledge: Critical thinking skills and knowledge of children whom may have a behavioral health diagnosis. The ability to be a team player and meticulous with notations, keeping records as well keeping a clean environment. A learning attitude. Training curriculum: Relias, SAMHSA approved curriculum, and Effective Fulfillment curriculum." "Skill and Knowledge assessment: Personnel must demonstrate the necessary skills and knowledge ...

Deficiency cited, complaint and compliance (annual) : 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 sufficient personnel members were present on a 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 the personnel members provided behavioral health services that they are not able to provide. A review of the facility's staffing schedule for July 2026 revealed E1, E3, E4, E5, and E6 working various shifts and have been scheduled to work alone on several dates. A review of E1's, E2's, E3's, E4's, and E5's personnel records revealed no documentation or evidence that E1, E2, E3, E4, or E5 had the skills and knowledge necessary to provide behavioral health services to children who may have behavioral health diagnoses and/or developmental disabilities. In an interview, E1 reported providing group therapy two to three times a week, which included online videos, "mood of the week," "life skills," and "anger management." E1 reported to never receive clinical oversight for the services provided. A review of an incident report dated July 24, 2026, revealed that three residents were involved in "inappropriate relations (sexual)." The report indicated that R1 showed E3 that R1 had "bruises on both arms, legs, back, stomach, and buttocks" and that R1 reported to R1's parent that another resident sexually assaulted R1. The report indicated that R3 contacted the ...

Deficiency cited, complaint and compliance (annual) : 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 documentation review, record review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel member that included documentation of cardiopulmonary resuscitation training. The deficient practice posed a risk as a personnel member's CPR training did not include an in-person demonstration. 1. A review of facility documentation revealed a policy titled, "Staff Management and Staff Records." The policy stated, "...All BHT's or staff must fill out a criminal history affidavit before working in our facility, also a fingerprint card and CPR/First Aid certifications are to be completed in person during orientation. 2. A review of facility documentation revealed a policy titled, "Client Independent Living & Staff Certifications." The policy stated, "All staff must complete CPR and first aid training to ensure they can provide immediate assistance in emergencies. Training will be conducted by qualified instructors and must be renewed periodically.... Content Includes:... Each training session will include a hands-on demonstration where individuals must demonstrate their ability to perform CPR effectively on a training manikin." 3. A review of E3's personnel record revealed E3 was hired in April 2026 as the lead behavioral health technician. E3's personnel file revealed CPR training completed online through "NationalCPRFoundation." E3's personnel record did not reveal CPR training that included an in-person hands-on demonstration. ...

Deficiency cited, complaint and compliance (annual) : R9-10-706.H.1.a. Personnel H. An administrator shall ensure that personnel records are: 1. Maintained: a. Throughout an individual's period of providing ...

Based on record review and interview, the administrator failed to ensure a personnel record was maintained throughout an individual's period of providing services in or for the behavioral health residential facility. The deficient practice posed a risk if an individual was not fit to work within a behavioral health residential facility. A review of R2's medical record revealed E8 digitally signed individual therapy notes. The Compliance Officer requested to review E8's personnel record, hired as a "counselor." However, E8's personnel record was not provided for review. In an interview, E3 reported that E8 was E7's employee and conducted therapy using telehealth. E3 confirmed that E8 did not have a personnel record for the behavioral health residential facility.

Deficiency cited, complaint and compliance (annual) : R9-10-707.A.1.b. Admission; Assessment A. An administrator shall ensure that: 1. A resident is admitted based upon: b. The resident's behavioral health issue ...

Based on documentation review, record review, and interview, the administrator failed to ensure the resident's behavioral health issue and treatment needs were within the behavioral health residential facility's scope of services. The deficient practice posed a risk as a resident requiring a higher level of care was admitted to the residential facility without a primary behavioral health diagnosis. 1. A review of facility documentation revealed a policy and procedure titled, "Scope of Service." The policy stated, "The description of available services includes but are not limited to: Behavioral Health services, Independent Living Training, provide safe quarters, provide athletic training and skill development (optional, based on interest), provide positive role models, creative arts development (optional, based on interest), and direction towards college, vocational, or career opportunities. Electronic Records will be used to document developmental history of the client. The facility may offer contracted behavioral health services and keep necessary documentation of those services as outlined in (R9-10-705)... Admission will be based on behavioral health diagnosis." 2. A review of R2's medical record revealed R2's primary diagnoses as Autism Spectrum Disorder, Cannabis Use Disorder, Mild, and Unspecified Depressive Disorder. R2's medical record revealed R2 received services through the Department of Economic Security, Developmental Disabilities Division. 3. A review of R2's ...

Deficiency cited, complaint and compliance (annual) : R9-10-711.B.1. Resident Rights B. An administrator shall ensure that: 1. A resident is treated with dignity, respect, and consideration;

Based on documentation review and interview, the administrator failed to ensure that a resident was treated with dignity, respect, and consideration. The deficient practice posed a risk as it was alleged the behavioral health technician failed to intervene when R1 was being assaulted by R2 and R3, and the Department was provided false or misleading information. A review of an incident report dated July 24, 2026, revealed that three residents were involved in "inappropriate relations (sexual)." The report indicated that R1 showed E3 that R1 had "bruises on both arms, legs, back, stomach, and buttocks" and that R1 reported to R1's parent that another resident sexually assaulted R1. The report indicated that R3 contacted the Administrator, E2, and E2 directed E3 to take R1 to the emergency room for a "rape kit." The incident report further indicates that R2 and R3 were the alleged perpetrators of the assault. A review of the discharge paperwork from the hospital confirmed that R1 was evaluated for sexual assault and had contusions. In an interview over the telephone, E2 originally reported being unaware that there were any allegations of sexual or physical assault. The Compliance Officer reviewed photos of R1's injuries taken by E3. The injuries were consistent with what was included in the incident report. The photos also confirm that E2 received the photos in a group chat room between staff. One of the messages sent at approximately 6:22 PM stated, "Boss.. we have an ...

Deficiency cited, complaint and compliance (annual) : 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 a resident admitted to a behavioral health residential facility with limited ability to function independently received continuous protective oversight. The deficient practice posed a risk as the lack of oversight led to an incident requiring law enforcement involvement. 1. A review of R1's, R2's, and R3's medical records revealed incident reports dated July 21, 2026. The incident reports stated, "...at around 5pm this afternoon, [E4] took [R1, R2, and R3] to go to multiple stores to kill some time and get out of the house for a bit. while transitioning from one store to another, [R1, R2, and R3] ran from [E4] and hid from [E4]. According to the police, they lifted [sic] from 3 stores. "Ross", "Five Below", and "Target." It was at "Target" that Loss Prevention caught [R1, R2, and R3] and when cops were called." 2. A review of R1's medical record revealed an incident report completed on July 25, 2026; however, the date of the incident was July 24, 2026. The incident report stated, "Around 5:30 pm, [E3] was prepping dinner and [R1] came up to [E3] and showed [E3] bruises on both arms, legs, back, stomach, and buttocks. [R1] had asked to call [R1's] [parent] so [E3] let [R1]. A few minutes later [R1] came back inside and said that [R1] [parent] wanted to talk to me. [E3] agreed and told [R1] that [E3] will take the call out front. While on the phone with [R1's parent], [R1] had made ...

Deficiency cited, complaint and compliance (annual) : R9-10-716.A.7.b. Behavioral Health Services A. An administrator shall ensure that: 7. A resident does not: b. Share any space, participate in any activity or ...

Based on documentation review, record review, and interview, the administrator failed to ensure a resident did not share any space, participate in any activity or treatment, or verbally or physically interact with any other resident that may have presented a threat to the resident's health or safety, based on the other resident's documented diagnosis, treatment needs, developmental levels, social skills, and personal history. The deficient practice posed a risk as the facility received allegations of assault and/or abuse and did not implement an intervention that would protect the health and safety of all residents within the behavioral health residential facility. A review of the facility documentation revealed policies and procedures titled, "Investigation of Child Maltreatment." The policy stated, "In the case that there are any alleged or suspected incidents of child maltreatment... precautionary measures will be taken to prevent further risk to the child who allegedly suffered the maltreatment and potential risk to other children in care. These measures will include removal from the preying member(s)." A review of an incident report dated July 24, 2026, revealed that three residents were involved in "inappropriate relations (sexual)." The report indicated that R1 showed E3 that R1 had "bruises on both arms, legs, back, stomach, and buttocks" and that R1 reported to R1's parent that another resident sexually assaulted R1. The report indicated that R3 contacted the ...

Deficiency cited, complaint and compliance (annual) : R9-10-716.F.1.b.i. Behavioral Health Services F. An administrator shall ensure that: 1. A personnel member whose job description includes the ability to use an ...

Based on documentation review, record review, and interview, the administrator failed to ensure a personnel member whose job description included the ability to use an emergency safety response completed training in crisis intervention before providing behavioral health services. The deficient practice posed a risk as a personnel member obtained the required training after providing behavioral health services. 1. A review of the facility documentation revealed a policy titled, "Level System and Dealing With Difficult Youth Development." The policy stated, "The Personnel Department shall ensure that all employees provide the following documents to be copied and placed in all employee personnel files prior to employment... If applicable, any licenses or certifications such as CPI." 2. An initial review of E3's (hired as a lead behavioral health technician) personnel record revealed no documentation of training in emergency safety response available for review. 3. At 6:50 PM on July 27, 2026, E3 provided a photo from E3's phone reflecting E3 had completed "CPI NonViolent Crises Intervention Training" on July 18, 2026. E3 reported E3 had not received any training prior to the training on July 18, 2026. 4. In an interview, E3 reported E3 was hired in April 2026 and began working at the current residential facility as the "House Lead" in May 2026. E3 reported that since hire, E3 has provided behavioral health services including assistance in the self-administration of medication ...

Deficiency cited, complaint and 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, observation, and interview, the administrator failed to ensure that assistance in the self-administration of medication was provided to a resident in compliance with an order. The deficient practice posed a risk if the resident experienced a change in condition due to improper assistance in the self-administration of medication. Finding include: 1. A review of R2's medical record revealed R2 received assistance in the self-administration of medication. A review of R2's medical record revealed a medication order for "Risperdal 2 mg tablet take one tablet oral at bedtime" and "Seroquel 50 mg take one table oral at bedtime." 2. A review of R2's medical record revealed a medication administration record (MAR) dated in July 2026. The MAR revealed "Risperdal" was last taken by R2 on July 24, 2026, and "Seroquel" was last taken by R2 on July 25, 2026. 3. The Compliance Officer observed R2 receive assistance in the self-administration of medication from E4. The Compliance Officer observed R2's medications did not include "Seroquel" and "Risperdal." The Compliance Officer observed R2 inform E4 that R2 wanted R2's "anxiety medication." The Compliance Officer observed E4 inform R2 the medication was not available. 4. In an interview, E3 reported R2 ran out of the identified medications and had not received a refill. E3 reported E3 contacted the pharmacy for a refill; however reported there was an issue with the insurance. E3 did not have any additional ...

Deficiency cited, complaint and compliance (annual) : R9-10-719.C.2. Food Services C. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator ...

Based on observation and interview, the administrator failed to ensure that food was stored and protected from potential contamination. The deficient practice posed a risk as the food was exposed to potential contamination. 1. During a facility tour with E1, the Compliance Officer observed what appeared to be peach cobbler in a baking dish stored in the facility kitchen fridge with a paper towel set on top of the cobbler. The food was not sealed or stored or protected from potential contamination. 2. In an interview, E1 reported the identified food stored in the fridge with a paper towel was peach cobbler. E1 acknowledged the food was not sealed or protected from potential contamination. 3. In an exit interview with E3, the findings were reviewed with no additional information to add.

Deficiency cited, complaint and compliance (annual) : R9-10-721.A.1.b. Environmental Standards A. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an ...

Based on documentation review, observation, and interview, the administrator failed to ensure that the premises and equipment were cleaned and, if applicable, disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection. The deficient practice posed a risk as the facility was not clean or disinfected. 1. A review of facility documentation revealed a policy titled, "Infection Control." The policy stated, "The facility is to be cleaned by staff and youth on a daily basis to prevent the spread of any infectious diseases and to maintain proper sanitation..." 2. During a facility tour with E1, the Compliance observed the following: -Food wrappers located in the bathroom and on bedroom floors; -Dirt and debris located on the resident bedroom floors and bathrooms; -Eggshells and egg yolk located in the resident's bathtub, bathroom floor, bedroom floors, and the backyard; -What appeared to be dirt stains located on the bedroom doors and walls; -Soiled underwear located on the bathroom floor; and -What appeared to be dirt and stains on the resident's sheets and blankets. 3. In an interview, E1 reported no knowledge of the identified debris appearing in the residential facility. However, E1 acknowledged the residential facility was not maintained clean and free from potential infectious disease. 4. In an exit interview with E3, the findings were reviewed with no additional information to add.

Deficiency cited, complaint and compliance (annual) : R9-10-721.A.14. Environmental Standards A. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an ...

Based on documentation review, observation, and interview, the administrator failed to ensure that poisonous or toxic materials stored by the behavioral health residential facility were maintained in labeled containers in a locked area inaccessible to residents. The deficient practice posed a risk as the toxic materials were accessible to residents which posed a risk to the physical health and safety of residents. 1. A review of the facility documentation revealed a policy titled, "FACILITY MAINTENANCE PROCEDURES FOR INDOOR ENVIRONMENTAL REQUIREMENTS." The policy stated, "All potentially dangerous objects or toxic substances shall be stored in a locked cabinet or enclosure, away from food or other areas that could constitute a hazard to the youth." 2. During a facility tour with E1, the Compliance Officer observed disinfectant wipes unlocked and stored by the facility in a kitchen cabinet. The Compliance Officer observed laundry detergent unlocked and stored by the facility in the laundry room. 3. In an interview, E1 reported the identified toxic materials were stored by the facility unlocked. 4. In an exit interview with E3, the findings were reviewed with no additional information to add.

Deficiency cited, complaint and compliance (annual) : R9-10-722.B.6. Physical Plant Standards B. An administrator shall ensure that: 6. If a resident bathroom door locks from the inside, an employee has a key and ...

Based on observation and interview, the administrator failed to ensure that if a resident bathroom door locked from the inside, an employee had a key and access to the bathroom. The deficient practice posed a risk as the employee had no means of unlocking the resident bathroom door in case of emergency. 1. During a facility tour with E1, the Compliance Officer observed a shared resident bathroom. The bathroom door locked from the inside. The Compliance Officer observed E1 was unable to unlock the bathroom door and did not have a key. 2. In an interview, E1 reported E1 did not have a key and could not unlock the resident bathroom door. 3. In an exit interview with E3, the findings were reviewed with no additional information to add.

Deficiency cited, complaint and compliance (annual) : R9-10-722.B.8.c. Physical Plant Standards B. An administrator shall ensure that: 8. A resident bedroom complies with the following: c. Contains a door that ...

Based on documentation review, observation, and interview, the administrator failed to ensure that a resident bedroom contained a door that opened into a hallway, common area, or outdoors. The deficient practice posed a risk to resident rights if a resident did not have privacy. 1. A review of facility documentation revealed a policy titled, "Facility Maintenance Procedures For Indoor Environmental Requirements". The policy stated, "Each health facility shall have complied with the following requirements:... The Home Facility shall be kept clean, in good repair and free of hazards such as cracks in floors, walks, or ceilings; warped or loosed boards, tile, linoleum, hand rails or railings; broken window panes; and any similar type hazards... Bedrooms shall meet the following requirements:.. All youth doors shall open directly into a corridor, a common area or the outside." 2. During a facility tour with E1, the Compliance Officer observed R1's and R4's shared bedroom door had been removed from the hinges and was balanced in the door frame. R1's and R4's bedroom did not contain a door that opened to the hallway. 3. In an interview, E1 reported the bedroom door had been broken by a resident. E1 acknowledged R1's and R4's shared bedroom did not contain a door that opened into the hallway. 4. In an exit interview with E3, the findings were reviewed with no additional information to add.

Deficiency cited, complaint and compliance (annual) : A.R.S. § 36-425.03. Children's behavioral health programs;personnel; fingerprinting requirements; exemptions; definitions A. Except as provided in subsections ...

Based on documentation review, record review, and interview, the administrator failed to ensure a personnel certifies 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. The deficient practice posed a risk if E3 was a danger to a vulnerable population. A.R.S. § 36-425.03.E: E. Children's behavioral health program personnel shall certify on forms that are provided by the department and notarized that they are not awaiting trial on or have never been convicted of or admitted in open court or pursuant to a plea agreement to committing any of the offenses listed in section 41-1758.03, subsection B or C in this state or similar offenses in another state or jurisdiction. 1. A review of Department documentation revealed the facility was licensed to provide behavioral health services to individuals under 18 years of age. 2. A review of E3's personnel record revealed no evidence of compliance with A.R.S. § 36-425.03. 3. A review of email correspondence revealed an email from E8, which reported E3 does not have a criminal history affidavit in E3's personnel record. 4. In an exit interview, the findings were reviewed with E1 and no additional comments, statements, or documentation were provided regarding the ...

Deficiency cited, complaint and compliance (annual) : 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 documentation review, record review, and interview, the administrator failed to ensure a medical practitioner performed a medical history and physical examination or a registered nurse performed a nursing assessment on a resident within 30 calendar days before admission or within 72 hours after admission and documented the medical history and physical examination or nursing assessment in the resident's medical record within 72 hours after admission for one of two medical records sampled. The deficient practice posed a risk of not meeting a resident's needs if no medical history and physical examination or nursing assessment were completed to assess a resident's needs prior to treatment as this information was required for the development and implementation of a treatment plan, per R9-10-708.A.1. 1. A review of the facility's policies and procedures (dated June 25, 2026) revealed a document titled, "ADMISSION AND INTAKE; CRITERIA; PROCESS; RESTRICTIONS (R9-10-707)." The policy stated “...Both planned and emergency admissions and intake will be treated in the exact same manner as followed: Fill and file the following forms:...History and Physical/Nursing Assessment within 72 hours ....Within 72 hours of a client’s admission, a BHT staff member with the approved training, or a licensed medical practitioner, shall perform or schedule the following:...Nursing Assessment. If not completed in 48 hours the nurse will be notified in order to get it done in the compliant time ...

Deficiency cited, complaint and compliance (annual) : R9-10-708.A.1. Treatment Plan A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that: 1. Is based on the ...

Based on record review and interview, the administrator failed to ensure a treatment plan was developed and implemented for each resident which was based on the nursing assessment required in R9-10-707(A)(6), for one of two resident records sampled. The deficient practice posed a risk as this information was required for the development and implementation of a treatment plan. R9-10-707.A.6: Except as provided in subsection (E)(1)(a), a medical practitioner performs a medical history and physical examination or a registered nurse performs a nursing assessment on a resident within 30 calendar days before admission or within 72 hours after admission and documents the medical history and physical examination or nursing assessment in the resident’s medical record within 72 hours after admission; 1. A review of R1’s (admitted in 2025) medical record revealed an initial treatment plan was developed and implemented approximately two days after R1's date of admission. However, there was no documentation of a completed physical examination or nursing assessment, as required by R9-10-707.A.6. 2. In an interview, E1 acknowledged R1's treatment plan was not based upon R1's medical history and physical examination or nursing assessment. 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 and compliance (annual) : R9-10-722.B.8.k. Physical Plant Standards B. An administrator shall ensure that: 8. A resident bedroom complies with the following: k. Has a clothing rod or ...

Based on observation and interview, the administrator failed to ensure a resident bedroom had a clothing rod or hook in the bedroom designed to minimize the opportunity for a resident to cause self-injury, in three residents' bedrooms. The deficient practice posed a ligature risk to residents. 1. The Compliance Officer observed white PVC rods and triangular metal brackets with hooks in three residents' bedrooms. The rods and hooks were sturdy and did not give way when the Compliance Officer applied downward pressure. 2. The Compliance Officer observed E1 ask a resident to apply pressure on the white PVC rod. The rods and hooks did not give way when the resident applied downward pressure. 3. In an interview, E1 acknowledged the clothing rods were not designed to minimize the opportunity for a resident to cause self-injury, and reported the facility will remove the triangular metal brackets with hooks and cut the white PVC rods in half to be in compliance with R9-10-722.B.8.k. 4. In an exit interview, the findings were reviewed with E1, and no additional comments, statements, or documentation were provided.

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 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 a resident. The deficient practice posed a risk to R1's health and safety as the facility did not have 1:1 staff with line of sight, 24 hours a day as indicated the R1's treatment plan, when R1 was able to leave the behavioral health residential facility without staff's knowledge, and 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 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 R1's medical record revealed a document titled, "Comprehensive Diagnostic Assessment/Biopsychosocial," dated in early March 2026. The document stated "...History of Physical and verbal aggression, suicidal ideation, self harm, running away, ADHD, unspecified trauma and stressor related disorder, disruptive mood dysregulation disorder...[R1] has a history of running away going back to when [R1] was 4 years old...The team hopes that with the support from a 1-1 in a BHRF setting, the resident will have opportunities to work through [R1's] ...

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, 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 risk to R1's and R2's health and safety as both residents were able to leave the behavioral health residential facility without the personnel member's knowledge.  1. A review of Department documentation revealed the facility 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 R1's medical record revealed R1 was admitted to the facility in early March 2026. 3. A review of R1's medical record revealed a document titled, "Comprehensive Diagnostic Assessment/Biopsychosocial," dated in early March 2026. The document stated "...History of Physical and verbal aggression, suicidal ideation, self harm, running away, ADHD, unspecified trauma and stressor related disorder, disruptive mood dysregulation disorder...[R1] has a history of running away going back to when [R1] was 4 years old...The team hopes that with the support from a 1-1 in a BHRF setting, the ...

Deficiency cited, complaint : R9-10-721.A.4.a. Environmental Standards A. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an ...

Based on documentation review, observation, and interview, the administrator failed to ensure equipment used at the behavioral health residential facility was maintained in working order. The deficient practice posed a risk as a window alarm intended to prevent unauthorized egress was non-functional, allowing R1 and R2 to exit through the window without a personnel member's awareness. 1. A review of facility documentation revealed an incident report for R1 dated April 8, 2026. The document stated, "...Time of Incident: 6:30 AM...AWOL...Resident climbed out of back master bedroom window and eloped without staffs [sic] knowledge...At approximately 6:30 AM staff became aware that [R1] were [sic] no longer in the residence. Staff [E3] conducted an immediate room check, and discovered that the resident had exited the master bedroom through the window without staffs knowledge or permission. The blinds were found at a slant and lifted up indicating the point of exit. [R1] was last observed in the residence approximately at 6:28 AM, being prompted by staff to return to bedroom. [sic] to get dressed for the day/[R1's] school intake meeting. Staff [E3] conducted active search efforts, inside and outside of residence, while maintaining supervision of remaining residence [sic] in the home. Immediate supervisor was notified, law-enforcement was notified, as well as Arizona department of child safety...The resident appeared to be fine right before the incident..." The document was ...

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, record review, and interview, the administrator failed to ensure policies and procedures for behavioral health services and physical health services were implemented to protect the health and safety of a resident which covered emergency safety responses. The deficient practice posed a risk as the established and documented policies and procedures of emergency safety response were not implemented. 1. A review of the facility’s policies and procedures (dated March 23, 2026) stated, "Policy...[sic]. 3Behavioral Management [sic]...The facility will implement a proactive approach to manage residents exhibiting sudden, intense, or out-of-control behaviors. Staff will be trained to respond effectively to such situations, prioritizing the safety and well-being of the resident in distress and others in the vicinity...Procedure... Immediate Response: De-escalation: Trained staff will approach the resident calmly, using de-escalation techniques (e.g., active listening, validating feelings). Safety Protocols: If the resident poses an immediate risk, staff will follow safety protocols, which may include: Moving other residents to a safe area. Using verbal redirection. If necessary, applying physical intervention techniques as a last resort, ensuring it complies with facility policy..." 2. A review of the facility’s policies and procedures (dated March 23, 2026) revealed a policy titled, “BEHAVIOR MANAGEMENT.” The policy stated, “...Therapeutic holds and ...

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 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 a resident. The deficient practice posed a risk as personnel members did not have relevant training on the premises to safely manage the sudden, intense, or out-of-control behavior of a resident, which resulted in E1 therapeutically holding R1 instead of using de-escalation technique. 1. A review of the facility’s policies and procedures (dated March 23, 2026) revealed a policy titled, “BEHAVIOR MANAGEMENT.” The procedure stated, “...Therapeutic holds and restrictive techniques will follow the guidelines of your CPI training. Therapeutic holds should only be made if it is safe to do so without harming yourself, observing youth, and the youth involved with the incident. The determination of using a therapeutic hold is if a youth is out of control, damaging property and harming himself or another youth. If a therapeutic hold is performed on a youth, staff must file an “Incident Report” and send it to the corporate administration team for review. A total internal investigation will take place to assure the proper steps and maneuvers were taken. A report of the investigation will be filed into the staff personnel folder. Any behavior management techniques that involve hurting or ...

Deficiency cited, complaint : R9-10-703.M.1-3. Administration M. An administrator shall ensure that the following information or documents are conspicuously posted on the premises and are ...

Based on observation and interview, the administrator failed to ensure the behavioral health residential facility's current license was conspicuously posted on the premises. 1. The Compliance Officer observed a posted behavioral health license. However, the license was for BH10297. 2. In an interview, E1 acknowledged the posted license was for a sister facility and not the facility where the inspection was being conducted. 3. In an exit interview, the findings were reviewed with E2 , and E2 reported to be unsure why a different facility's license was posted.

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 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 a resident. The deficient practice posed a risk as there was not enough trained personnel members on the premises to safely manage the sudden, intense, or out-of-control behavior of a resident who had to be taken into the hospital. 1. A review of facility documentation revealed a document titled "Incident Report" dated in February 2026 that stated "[R1] was returned by Phoenix Police Department at approximately 7:00 p.m., about one hour after leaving the facility without authorization (AWOL). Staff informed the officers that we were unable to accept the client back. However, the officers advised that they could not transport [R1] to the hospital or to juvenile detention and stated that we were required to take [R1] back. They did offer to follow this writer if transportation to either location was arranged. This writer explained to the officers that only one staff member was on site and that other clients were present. After this discussion, the officers reiterated that we needed to accept the client back into the facility. Upon returning, the client sat calmly on the couch for approximately 45 minutes. After the officers left, the client began acting out again, stating that [R1] ...

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 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 as a resident under the age of 18 left the facility and did not receive continuous protective oversight. A.R.S. § 36-401.A. 13. "Continuous" means available at all times without cessation, break or interruption. 1. A review of R1's medical record revealed R1 was under the age of 18. 2. A review of facility documentation revealed a document titled "Incident Report," dated in February 2026. The document stated "[R1] was on restrictions and attempted to defy those restrictions. When this writer attempted to hold [R1] accountable [R1] went AWOL walking out the door down the street towards camelback pd reference #is 223143." The document was digitally signed by E4. 3. A review of facility documentation revealed a document titled "Incident Report" dated in February 2026 that stated "[R1] was returned by Phoenix Police Department at approximately 7:00 p.m., about one hour after leaving the facility without authorization (AWOL). Staff informed the officers that we were unable to accept the ...

Deficiency cited, complaint : R9-10-721.A.1.c. Environmental Standards A. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an ...

Based on observation, record review and interview, the administrator failed to ensure the premises were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a risk as possible ligature points and possible dangerous items were identified. 1. The Compliance Officer observed R1's bedroom (now occupied by R3) closet contained wall-mounted wired shelves and brackets. 2. The Compliance Officer observed R2's and R4's shared bedroom closet contained wall-mounted wired shelves and brackets. 3. The Compliance Officer observed an acrylic bar in R2's and R4's shared bathroom. The acrylic bar did not give way when the Compliance Officer applied downward pressure. 4. The Compliance Officer observed, scattered in the back yard, various items of concern including pieces of broken metal furniture, broken pieces of wood with exposed nails, piles of bricks, rusted pieces of metal and broken shards of wood. 5. A review of R1's medical record revealed R1 had a history of physical aggression, irritability, anxiety and depression. 6. In an interview, E1 reported R1 had an outburst earlier in the week and destroyed several items in the facility, including the items scattered in the backyard. E1 reported R1 had been physically aggressive on multiple occasions, including two days prior and had been taken to Mind 24-7. 7. In an exit interview, the findings were reviewed with E2, and no additional comments or ...

Deficiency cited, complaint : R9-10-721.A.14. Environmental Standards A. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an ...

Based on observation and interview, the administrator failed to ensure poisonous or toxic materials stored by the behavioral health residential facility were maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and were inaccessible to residents. 1. The Compliance Officer observed a bottle of Windex underneath the unlocked kitchen sink. The bottle contained a toxic warning label. 2. The Compliance Officer observed a canister of air freshener on a hallway table. The canister contained a toxic warning label. 3. The Compliance Officer observed an unlocked laundry room. The laundry room contained a bottle of multi-purpose cleanser on a laundry room shelf and laundry detergent on top of the dryer. The bottles contained toxic warning labels. 4. The Compliance Officer observed an unlocked garage. The garage contained an unlocked cabinet which contained bottles of multi-purpose cleanser, Windex, bleach and laundry detergent. The containers contained toxic warning labels. 5. The Compliance Officer observed one resident onsite during the inspection. 6. In an interview, E1 acknowledged the poisonous or toxic materials throughout the facility were unlocked and accessible to residents. 7. In an exit interview, the findings were reviewed with E2, and no additional comments or documentation were provided for review.

Deficiency cited, complaint and compliance (annual) : R9-10-703.A.2.a-b. Administration A. A governing authority shall: 2. Establish, in writing: a. A behavioral health residential facility's scope of services ...

Based on record review, documentation review, and interview, the governing authority failed to establish, in writing, qualifications for an administrator. The deficient practice posed a risk if the administrator did not have the qualifications required by the governing authority. 1. The Compliance Officer requested to review E1’s personnel record at 10:05 am, per R9-10-706.H.1.a. 2 A review of E1's (unknown DOH and hired as an administrator) personnel record, provided by email during the onsite inspection, revealed no established written qualifications for an administrator. 3. A review of the facility's policies and procedures (effective date September 1, 2023) revealed no established written qualifications for an administrator. 4 A review of facility documentation revealed no established written qualifications for an administrator 5. In an interview, E1 acknowledged the facility's policies and procedures did not include the qualifications for an administrator.  6. In an exit interview, the findings were discussed with E1, and no additional statements or documentation were provided.

Deficiency cited, complaint and compliance (annual) : R9-10-703.B.3. Administration B. An administrator: 3. Except as provided in subsection (A)(6), designates, in writing, an individual who is present on the ...

Based on observation, documentation review, and interview, the administrator failed to designate, in writing, an individual who was present on the premises of the behavioral health residential facility and accountable for the facility when the administrator was not present on the behavioral health residential facility's premises. The deficient practice posed a risk as E5 and E9 were not present on the premises and accountable for the facility when E1 was not present on the premises and accountable for the facility. 1. The Compliance Officer observed there were no personnel members or residents on the premises at approximately 9:55 A.M. 2. The Compliance Officer observed E1 arrive at the facility at approximately 12:00 P.M. 3. In an interview, E1 reported E5 was the individual designated by E1 as the individual to be present on the premises of the facility and accountable for the facility when the administrator was not present on the facility’s premises. 4. The Compliance Officer observed a posting on the wall in the hallway. The posting indicated E9 was designated by E1 as the individual to be present on the premises of the behavioral health residential facility and accountable for the facility when E1 was not present on the behavioral health residential facility's premises. However, the posting did not indicate E5 was designated by E1 as the individual to be present on the premises of the behavioral health residential facility and accountable for the facility when E1 was ...

Deficiency cited, complaint and compliance (annual) : R9-10-703.K.8.a-c. Administration K. An administrator shall: 8. Maintain a written log of unauthorized absences for at least 12 months after the date of a ...

Based on record review, documentation review, and interview, the administrator failed to maintain a written log of unauthorized absences for at least 12 months after the date of a resident's absence to include the name of the resident absent without authorization, the individual to whom the report was submitted, and the date of the report. The deficient practice posed a risk as this information is used to evaluate and take action related to unauthorized absences under the quality management program in R9-10-704, per T9-20-703.K.9. 1. A review of R1’s medical record revealed an incident report dated in November 2025. The incident report summarized an unauthorized absence. 2. A review of facility documentation revealed no documentation of a written log of unauthorized absences. 3. In an interview, E1 reported the facility’s unauthorized absences were documented in incident reports, and acknowledged a written log of unauthorized absences was not maintained.

Deficiency cited, complaint and compliance (annual) : 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, observation, and interview, the administrator failed to ensure a plan was established and documented for an ongoing quality management program that, at a minimum, included a method to make changes or take action as a result of the identification of a concern about the delivery of services related to resident care. 1. A review of facility documentation revealed a quality management plan (dated 2024). However, the program did not include a method to make changes or take action as a result of the identification of a concern about the delivery of services related to resident care. 2. A review of R1’s medical record revealed an incident report dated in November 2025. The incident report summarized R1's violent outburst and an unauthorized absence. 3. The Compliance Officer observed the door to the facility’s office contained two large holes. 4. In an interview, E1 reported R1 punched the holes through the door. 5. In an interview, E1 reported the incident report included the criteria required by the Rule. However, E1 was unable to provide an established and documented ongoing quality management program that, at a minimum, included a method to make changes or take action. 4. In an exit interview, the findings were discussed with E1, and no additional statements or documents were provided.

Deficiency cited, complaint and compliance (annual) : R9-10-706.G.3.a. 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 a personnel member to include documentation of the individual's qualifications, including skills and knowledge applicable to the individual's job duties, for one of two personnel members sampled. The deficient practice posed a risk if E1 did not have the qualifications to be accountable for, or to manage, the behavioral health residential facility. R9-10-703.B. An administrator: 1. Is directly accountable to the governing authority of a behavioral health residential facility for the daily operation of the behavioral health residential facility and all services provided by or at the behavioral health residential facility; 2. Has the authority and responsibility to manage the behavioral health residential facility; and 1. The Compliance Officer requested to review E1’s personnel record at 10:05 am, per R9-10-706.H.1.a. 2 A review of E1's (unknown DOH and hired as an administrator) personnel record, provided by email during the onsite inspection, revealed no documentation of E1's qualifications, including skills and knowledge applicable to E1's job duties. 3. A review of the facility's policies and procedures revealed no job description for an administrator. 4. In an interview, E1 reported believing there was no need to maintain a full personnel record for the administrator, as the administrator was the owner and rarely provided direct services to residents. 5. In an ...

Deficiency cited, complaint and compliance (annual) : R9-10-706.G.3.b. 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 a personnel member including documentation of the individual's education and experience applicable to the individual's job duties, for one of two personnel members sampled. The deficient practice posed a risk if E1 did not have the education and experience to be accountable for, or to manage, the behavioral health residential facility. 1. The Compliance Officer requested to review E1’s personnel record at 10:05 am, per R9-10-706.H.1.a. 2 A review of E1's (unknown DOH and hired as an administrator) personnel record, provided by email during the onsite inspection, revealed no documentation of E1’s education and experience applicable to the individual's job duties. 3. A review of the facility's policies and procedures revealed no job description for an administrator. 4. In an interview, E1 reported believing there was no need to maintain a full personnel record for the administrator, as the administrator was the owner and rarely provided direct services to residents. 5. In an exit interview, the findings were reviewed with E1, and no additional statements or documentation were provided.

Deficiency cited, complaint and compliance (annual) : 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 a daily staffing schedule included documentation of the hours worked by each employee. The deficient practice posed a risk as no accurate record was available to ensure shifts and tasks were covered. 1. A review of facility documentation revealed a daily staffing schedule dated November 2025. The daily staffing schedule included E6 worked at the facility on November 17, 2025, from 2:00 P.M. to 10:00 P.M., E7 worked at the facility from 10:00 P.M. to 7:00 A.M. on November 17, 2025 to November 18, 2025, and E8 worked from 7:00 A.M. to 10:00 P.M. on November 17, 2025. 2. A review of R1’s medical record revealed an incident report dated November 2025. The report indicated an incident time of 3:39 P.M., completed by E3. 3. In an interview, E1 reported E3 was present at the facility at the time of R1’s incident in November 2025. E1 reported E3 and E4 were the only personnel present at the facility at the time of the altercation. 4. In an interview, E1 reported E6 and E7 did not work on November 18, 2025. 5. In a joint interview, E1 acknowledged the daily staffing schedule did not include documentation of the hours worked by each employee. E1 acknowledged E6's and E7's hours worked on November 17, 2025, were not documented on the daily staffing schedule. E1 acknowledged E6 and E7 were not included on the daily staffing schedule on November 17, 2025. 6. In an exit interview, the findings ...

Deficiency cited, complaint and compliance (annual) : R9-10-711.A.1. Resident Rights A. An administrator shall ensure that: 1. The requirements in subsection (B) and the resident rights in subsection (E) are ...

Based on observation and interview, the administrator failed to ensure the requirements in subsection (B) and the resident rights in subsection (E) were conspicuously posted on the premises. The deficient practice posed a risk if residents were unaware of the requirements and the resident rights. 1. The Compliance Officer observed no conspicuously posted requirements in subsection (B) and the resident rights in subsection (E) on the premises. 2. The Compliance Officer observed a room with a sign on the door stating "office." The Compliance Officers were able to look into the office and no conspicuously posted requirements in subsection (B) and the resident rights in subsection (E) were observed. 3. In an exit interview, E1 acknowledged the requirements in subsection (B) and the resident rights in subsection (E) were not conspicuously posted.

Deficiency cited, complaint and compliance (annual) : R9-10-719.C.4. Food Services C. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator ...

Based on observation and interview, the administrator failed to ensure a refrigerator contained a thermometer, accurate to plus or minus 3° F, placed at the warmest part of the refrigerator. 1. The Compliance Officer observed the kitchen refrigerator contained foods requiring refrigeration, such as milk, cheese, and produce. However, no thermometer placed at the warmest part of the refrigerator was observed. 2. In an interview, E1 acknowledged the refrigerator did not contain a thermometer placed at the warmest part of the refrigerator. 3. In an exit interview, the findings were discussed with E1, and no additional statements or documentation were provided.

Deficiency cited, complaint and compliance (annual) : R9-10-720.B.1.a. Emergency and Safety Standards B. Except for an outdoor behavioral health care program provided by a behavioral health residential facility ...

Based on documentation review and interview, the administrator failed to ensure the developed and documented disaster plan included where residents will be relocated. The deficient practice posed a risk if employees were able to properly implement a disaster plan. 1. A review of facility documentation revealed a disaster plan dated July 21, 2025. The plan stated, "...Evacuation Plan,,,Transportation arrangements made for non-ambulatory clients…Emergency bags at exits ([medication, identification], contacts…Practice drills held quarterly…Reunification site: insert address]..." However, no relocation address was documented. 2. In an exit interview, E1 reviewed the findings, and no additional statements or documentation were provided.

Deficiency cited, complaint and compliance (annual) : R9-10-720.B.4. Emergency and Safety Standards B. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an ...

Based on documentation review and interview, the administrator failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were not able to implement a disaster plan. 1. A review of Department documentation revealed the perpetual license for BH10355 was effective on October 25, 2025. 2. A review of facility documentation revealed a document titled "Dalia Homecare Disaster Drill Form.” The document was dated August 20, 2025, at 3:05 P.M. However, no documentation indicating disaster drills were conducted on each shift every three months was available. 3. In an interview, E1 acknowledged disaster drills were not conducted on each shift every three months. E1 reported the facility maintained three shifts: 7:00 A.M.-10:00 P.M., 2:00 P.M.-10:00 P.M., and 10:00 P.M.-7:00 A.M. on Sundays through Saturdays. 4. In an exit interview, the findings were discussed with E1, and no additional statements or documentation were provided.

Deficiency cited, complaint and compliance (annual) : 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 medical history and physical examination or a registered nurse performs a nursing assessment on a resident within 30 calendar days before admission or within 72 hours after admission. The deficient practice posed a health risk as the resident could have had medical complications without notifying the staff.  1. A review of R1's medical record revealed a nursing assessment that was completed on July 8, 2025, five calendar days after the resident's admission to the facility. 2. In an interview, E1 reported nursing assessments are to be completed within 30 days after admission. 3. In an exit interview, the findings were reviewed with E1. No additional comments or documents were provided.

Deficiency cited, initial monitoring : A.R.S. § 36-407.A. Prohibited acts; required acts A. A person shall not establish, conduct or maintain in this state a health care institution or any class or ...

Based on observation and interview, the administrator failed to maintain in this state a health care institution with the approved capacity, occupancy, and operations of the subclass of health care institution for which the Department issued a valid license. The deficient practice posed a risk as the current capacity, occupancy, and operations of the health care institution were outside the scope of the licensed behavioral health residential facility subclass. R9-10-101(195) "Resident" means an individual living in and receiving physical health services or behavioral health services, including rehabilitation services or habilitation services if applicable, from a nursing care institution, an intermediate care facility for individuals with intellectual disabilities, a behavioral health residential facility, an assisted living facility, or an adult behavioral health therapeutic home. 1. The Compliance Officer observed O1 answer the door. The Compliance Officer observed three individuals inside the facility. 2. In an interview, O1 reported that there were no residents and no staff on-site at the facility. However, O1 reported O1 was a contracted maintenance worker, and O1 was staying at the facility with O1's two children while completing the maintenance work. O1 reported E2 was letting O1 and O1's two children live at the facility temporarily for the week while O1 completed maintenance work. 3. The Compliance Officer was unable to enter the facility due to the absence of ...

Deficiency cited, initial monitoring : A.R.S. § 36-424.C. Inspections; suspension or revocation of license; report to board of examiners of nursing care institution administrators and assisted ...

Based on documentation review, observation, and interview, the licensee failed to provide complete acquiescence in any entry or inspection of the premises during the term of the license. The deficient practice posed a risk as the Department was unable to determine substantial compliance. 1. A review of Department documentation revealed the facility's perpetual license was effective in October 2024. 2. The Compliance Officer observed O1 answer the door. The Compliance Officer observed three individuals inside the facility. 3. In an interview, O1 reported there were no residents and no staff on-site at the facility. However, O1 reported O1 was a contracted maintenance worker, and O1 stayed at the facility with O1's two children while completing the maintenance work. O1 reported that E2 was letting O1 and O1's two children live at the facility temporarily for the week while O1 completed maintenance work. 4. The Compliance Officer attempted to call the two phone numbers listed for the facility at 11:30 AM on February 26, 2025. However, there was no answer, and the Compliance Officer left voicemails. 5. At 1:15 PM, approximately one hour and 45 minutes after the attempted phone calls, the Compliance Officer received a phone call from E1. E1 confirmed that O1 was a contracted maintenance worker, and O1 was living at the facility while O1 completed maintenance work for the facility. E1 confirmed there were no residents and no staff present at the facility.

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 including initial training and continued competency training in fall prevention and fall recovery. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not implemented. 1. A review of facility documentation revealed a program regarding fall prevention and fall recovery was not available for review. 2. A review of E2's and E3's personnel record revealed documentation of initial training and continued competency in fall prevention and fall recovery was not available for review. 3. In an interview, E1 acknowledged the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery.

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 completed orientation as required by policies and procedures, for two of five personnel members sampled. 1. A review of facility documentation revealed a policy and procedure titled "R9-10-706 ORIENTATION" dated in 2024. The policy stated "The Program Director and Facility Manager shall ensure that all staff attends an orientation session within the first week of employment. Orientation shall include. A. Review of the facility's and personnel policies and procedures which include the following: 1. Child Management Techniques 2. Behavior Management Techniques 3. Review of Policies and Procedures 4. Health Care Issues and Procedures 5. Medication self-administration training from RN 6. Checking Certification in CPR and First-Aid (A website will be provided to obtain) 7. Skill related to Cultural and Ethnic Differences 8. Self-Awareness 9. Values 10. Professional Ethics..." 2. A review of E3's (hired in 2024) personnel record revealed E3 was hired as a behavioral health technician. E3's personnel record revealed documentation of E3's completed orientation was not available for review. 3. A review of E5's (hired in 2024) personnel record revealed E5 was hired as a behavioral health technician. E5's personnel record revealed documentation of E5's completed orientation was not ...

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 cardiopulmonary resuscitation (CPR) training and first aid training, if required for the individual according to R9-10-703(C)(1)(e), for two of five personnel sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. 1. A review of the facility's policies and procedures revealed a policy titled "CLIENT INDEPENDENT LIVING & STAFF CERTIFICATIONS" dated in 2024. "A minimum of 1 on duty BHT staff member must possess current and valid CPR and First Aid certification. 2. A review of the facility's staffing schedule revealed E2 was the only staffing working from 2:00 pm-10:00 pm shift on October 1-4, 2024 and October 7, 2024. 3. A review of the facility's staffing schedule revealed E3 was the only staffing working from 12:00 pm-8:00 am shift on October 2, 2024 and 4, 2024. 4. A review of E2's personnel record revealed documentation of current CPR training dated November 29, 2022, from "NationalCPRFoundation". The document stated "Valid for 2 years" 5. A review of the "nationalcprfoundation.com" website revealed the following statement: "National CPR Foundation is known for providing Life-Skill Techniques for longer more lasting lives. Harness the Power of Our Online Training and Earn Your Certification Today - The Smarter Way." 6. 4. A ...

Deficiency cited, complaint and compliance (annual) : A. An administrator shall ensure that a discharge plan for a resident is: 1. Developed that: a. Identifies any specific needs of the resident after discharge ...

Based on record review and interview, the administrator failed to ensure that a discharge plan for a resident is developed that identifies and specific needs of the resident after discharge and includes a description of the level of care that may meet the resident's assessed and anticipated needs after discharge for one of three residents sampled. 1. A review of R2's medical record revealed a document titled "Discharge Summary" dated December 30, 2023. The document stated "Discharge reason: Hospital Admission...Discharge Disposition: Moderate assistance required...Summary of care/status at discharge: Clients had trouble sleeping multiple nights and attacked staff multiple times on 12/29/23. Staff needed to restrain client multiple times and eventually gave the client a cpu [computer] to calm [R2] down finally...Discharge instructions: follow-up." The document was signed and dated by E1, however, the document did not include any specific needs of the resident after discharge and a description of the level of care that may meet the resident's assessed and anticipated needs after discharge. 2. In an interview, E1 acknowledged R2's medical record did not include include any specific needs of the resident after discharge and a description of the level of care that may meet the resident's assessed and anticipated needs after discharge.

Deficiency cited, complaint and compliance (annual) : B. An administrator shall ensure that: 1. A request for participation in developing a resident's discharge plan is made to the resident or the resident's ...

Based on record review and interview, the administrator failed to ensure a request for participation in developing the resident's discharge plan and an opportunity for participation in developing the resident's discharge plan was provided to the resident or the resident's representative and was documented in the resident's medical record, for one of three residents sampled. The deficient practice posed a risk if a resident's representation did not participate in goals and objectives for a resident in preparation for the patient's discharge. R9-10-101.77. "Discharge planning" means a process of establishing goals and objectives for a patient in preparation for the patient's discharge. 1. A review of R2's medical record revealed a document titled "Discharge Summary" dated December 30, 2023. The document stated "Discharge reason: Hospital Admission...Discharge Disposition: Moderate assistance required...Summary of care/status at discharge: Clients had trouble sleeping multiple nights and attacked staff multiple times on 12/29/23. Staff needed to restrain client multiple times and eventually gave the client a cpu [computer] to calm [R2] down finally...Discharge instructions: follow-up." However, the document did not include documented evidence a request for participation and an opportunity for participation were made to resident's representative. 2. In an interview, E1 acknowledged R2's medical record did not include documented evidence a request for participation and an ...

Deficiency cited, complaint and compliance (annual) : D. An administrator shall ensure that there is a documented discharge order by a medical practitioner or behavioral health professional before a resident is ...

Based on record review and interview, the administrator failed to ensure there was a documented discharge order by a medical practitioner or behavioral health professional before a resident was discharged, unless the resident leaves the behavioral health residential facility against a medical practitioner's or behavioral health professional's advice, for one discharged resident sampled. The deficient practice posed a risk if the discharge order had not been documented by a medical practitioner or behavioral health professional. 1. A review of R2's medical record revealed a document titled "Discharge Summary" dated December 30, 2023. The document stated "Discharge reason: Hospital Admission...Discharge Disposition: Moderate assistance required...Summary of care/status at discharge: Clients had trouble sleeping multiple nights and attacked staff multiple times on 12/29/23. Staff needed to restrain client multiple times and eventually gave the client a cpu [computer] to calm [R2] down finally...Discharge instructions: follow-up." 2. A review of R2's medical record revealed no documented discharge order by a medical practitioner or behavioral professional before R2 was discharged. 3. In an interview, E1 acknowledged R2's medical record did not include a documented discharge order by a medical practitioner or behavioral health professional before R2 was discharged.

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 included the requirements in R9-10-709(G)(2)(a)(ii-iv)(b), for one discharged resident sampled. 1. A review of R2's medical record revealed a document titled "Discharge Summary" dated December 30, 2023. The document stated "Diagnosis: F84.0...Presenting problems on admission: Autism spectrum disorder, disruptive mood dysregulation disorder, ADHD...Discharge reason: Hospital Admission...Discharge Disposition: Moderate assistance required...Summary of care/status at discharge: Clients had trouble sleeping multiple nights and attacked staff multiple times on 12/29/23. Staff needed to restrain client multiple times and eventually gave the client a cpu [computer] to calm [R2] down finally...Discharge instructions: follow-up." However, the discharge summary did not include the following: -A summary of the treatment provided to the resident; -The resident's progress in meeting treatment goals, including treatment goals that were and were not achieved; and -The name, dosage, and frequency of each medication ordered for R2 by a medical practitioner at the behavioral health residential facility at the time of R2's discharge; and -A description of the disposition of R2's possessions, funds, or medications brought to the behavioral health residential facility by R2. 2. In an interview, E1 acknowledged the missing requirements in R2's discharge summary.

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

Based on record review and interview, the administrator failed to ensure a resident's medical record contained orders, for one of three residents sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the required documentation was not in the medical record during the inspection. 1. A review of R1's medical record revealed a medication administration record (MAR) for the month of October 2024. The MAR revealed R1 received the following medications on the following dates and times: -"Olanzapine 10 mg capsule (give [R1] 1 tablet by mouth twice daily)" on October 1-8, 2024 at "AM" and October 1-7, 2024 at "PM"; -"Lithium Carbonate 300 mg (take 1 capsule by mouth twice daily)" on October 1-8, 2024 at "AM" and October 1-7, 2024 at "PM"; and -"Propranolol 10 mg (take 1 tab by mouth twice daily) on October 1-8, 2024 at "AM" and October 1-7, 2024 at "PM". 2. A review of R1's medical record revealed a document title "AFTER VISIT SUMMARY" dated March 6, 2024. The document stated "Your medication list...Lithium 300 mg capsule...Olanzapine 10 mg tablet...Propranolol 10 mg...Vitamin D3 50 mcg (2000 UT)..." The document listed R1's medications, however, the document did not contain medication orders. 3. In an interview, E1 acknowledged R1's medical record did not contain medication orders.

Deficiency cited, complaint and compliance (annual) : F. An administrator shall ensure that: 1. A personnel member whose job description includes the ability to use an emergency safety response: b. Completes ...

Based on interview and record review, the administrator failed to ensure a job description included a personnel member's ability to use an emergency safety response (ESR), and a personnel member completed training required in R9-10-716.F.1.a. at least once every twelve months after the personnel member completed the original training, for one of five sampled personnel members. 1. A review of R2 medical records revealed a document titled "Discharge Summary" dated December 30, 2023. The document stated "Discharge reason: Hospital Admission...Discharge Disposition: Moderate assistance required...Summary of care/status at discharge: Clients had trouble sleeping multiple nights and attacked staff multiple times on 12/29/23. Staff needed to restrain client multiple times and eventually gave the client a cpu [computer] to calm [R2] down finally..." 2. In an interview, E1 reported E6 (hired as a BHT) did not put R2 into a restraint, and E6 implemented the use of the ESR and R2 was placed into a therapeutic hold. 3. A review of the facility's policies and procedures revealed a policy titled "R9-10-706 QUALIFICATIONS OF SPECIFIC POSITIONS OR TASKS" The policy stated "BHT: Responsible for the direct care of the youth following the blueprint laid in agency's Policies and Procedures. Education: High School Diploma or at least 3 months of verifiable experience if no diploma. Experience: None needed. Skills and Knowledge: Critical thinking skills and knowledge of children whom may have a ...

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 in the assistance in the self-administration of medication included a demonstration of the personnel member's skills and knowledge necessary to provide assistance in the self-administration of medication, identification of medication errors, and medical emergencies related to medication that required emergency medical intervention, and the process for notifying the appropriate entities when an emergency medical intervention was needed, provided by a medical practitioner or registered nurse or an individual trained by a medical practitioner or registered nurse, for two of five personnel 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 E2's personnel record revealed a document titled "Staffing Training Record" dated February 3, 2024. The document stated "Dalla Homecare Intervention staff training policy is that full-time support staff members receive at least 4 hours of annual training, and full-time direct care staff members receive at least 24 hours of annual...Topic will cover: Medication self-administration training...EMPLOYEES THAT ATTENDED THE TRAINING:...E2." However, the documentation did not include: documentation the training was provided by a medical practitioner or registered nurse or an individual trained by a medical practitioner or registered nurse ...

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 record review 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 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 medical record revealed a medication order dated November 27, 2023 for "Vyvanse 40 mg capsule take 1 capsule by oral route every day in the morning." 2. A review of R3's medications revealed "Vyvanse 40 mg" was not available for review. 3. A review of R3's medication administration record (MAR) for October 2024 stated "Lisdexamfetamine [Vyvanse] 40 mg capsules take 1 capsule by mouth every morning." However, the MAR contained circled dates from October 1-8, 2024. 4. In an interview, E3 stated the circled dates meant the medication was not given. 5. In an interview, E1 reported insurance did not cover "Vyvanse 40 mg". E1 acknowledged assistance in the self-administration of medication provided R1 was not in compliance with an order.

Deficiency cited, complaint and 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, a residential care institution failed to ensure an employee had a valid fingerprint clearance card, for one of three personnel members sampled. The deficient practice posed a risk if E2 was a danger to a vulnerable population. 1. A review of E2's personnel record revealed a fingerprint clearance card with an issue date of September 7, 2021, and an expiration date of September 7, 2027. 2. A review of the Arizona Department of Public Safety (DPS) fingerprint clearance card verification website revealed E2's fingerprint clearance card status was "Not Valid." 3. In a telephonic interview, the Compliance Officer and E1 spoke with O1, a representative from DPS. O1 reported E2 was issued a valid fingerprint clearance card, however, E2's fingerprint clearance became invalid after E2's fingerprint clearance card was issued. 4. In an interview, E1 acknowledged E2's fingerprint clearance card was currently invalid.

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 this Article was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance. 1. A review of E4's (hired as a BHP) personnel record revealed documentation to demonstrate E4's skills and knowledge were verified and documented was not available for review. 2. A review of E2's (hired as a BHT) personnel record revealed documentation of E2's completed orientation was not available for review. 3. A review of E3's (hired as a BHT) personnel record revealed documentation of E3's completed orientation was not available for review. 4. A review of E4's personnel record revealed documentation of E4's completed orientation was not available for review. 5. In an interview, E1 acknowledged the aforementioned documentation was not provided to the Department within two hours after a Department request.

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 members to include documentation of the individual's skills and knowledge, for one of three personnel members sampled. The deficient practice posed a risk if E4 were unable to meet the needs of the residents, the Department was unable to determine substantial compliance as the documentation was not in the personnel record during the inspection, and the documentation was not provided within two hours after a Department request. 1. A review of the facility's policies and procedures revealed a policy titled "R9-10-706 QUALIFICATIONS OF SPECIFIC POSITIONS OR TASKS" dated March 15, 2022. The policy stated "BHP: Responsible for the therapy of our youth. Clinical oversite and maintaining company compliance with state requirements. Qualifications: Professional designation, must have the contracted individual's documentation." However, the policy did not include the skills and knowledge required for a behavioral health professional. 2. A review of E4's personnel record revealed documentation to demonstrate E4's skills and knowledge were verified and documented was not available for review. 3. In an interview, E1 reported E1 had documentation of E4's skills and knowledge, however, E1 could not locate the documentation. E1 acknowledged documentation to demonstrate E4's skills and knowledge were verified and documented was not available for ...

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 completed orientation as required by policies and procedures, for three of three personnel members sampled. The deficient practice posed a risk if E2, E3, and E4 were unable to meet the needs of the residents, the Department was unable to determine substantial compliance as the documentation was not in the personnel record during the inspection, and the documentation was not provided within two hours after a Department request. 1. Arizona Administrative Code (A.A.C.) R9-10-101.155. states "Orientation" means: "the initial instruction and information provided to an individual before the individual starts work or volunteer services in a health care institution." 2. A review of the facility's policies and procedures revealed a policy titled "R9-10-706 ORIENTATION" dated March 15, 2022. The policy stated "Upon hiring, all new hire staff will need to go through our 4-hour training process before working alone. Professional test may be given to ensure that enough pertinent information has been retained. Ongoing staff meetings will take place at least, but not limited to, once every 30 days." 3. A review of E2's (hired as a BHT) personnel record revealed documentation of E2's completed orientation was not available for review. 4. A review of E3's (hired as a BHT) personnel record ...

Deficiency cited, complaint and compliance (annual) : F. An administrator shall ensure that: 1. A personnel member whose job description includes the ability to use an emergency safety response: b. Completes ...

Based on documentation review, record review, and interview, the administrator failed to ensure a personnel member completed training in the use of an emergency safety response as required in subsection (F)(1)(a) before providing behavioral health services, for two of three personnel members sampled. 1. A review of the facility's policies and procedures revealed a job description for behavioral health technicians (BHT). However, the use of emergency safety response was not included. 2. A review of the facility's policies and procedures revealed a policy titled "R9-10-716 LEVEL SYSTEM AND DEALING WITH DIFFICULT YOUTH DEVELOPMENT" dated March 15, 2022. The policy stated "C. The Personnel Department shall ensure that all employees provide the following documents to be copied and placed in all employee personnel files within 30 days of start date of employment. 1. CPR and First Aid Certification 2. CPI training." 3. A review of E2's personnel record revealed crisis prevention training from the Crisis Prevention Institute, dated January 6, 2023. However, the emergency safety response training was not completed before E2 provided behavioral health services. 4. A review of E3's personnel record revealed crisis prevention training from the Crisis Prevention Institute, dated December 21, 2022. However, the emergency safety response training was not completed before E3 provided behavioral health services. 5. In an interview, E1 acknowledged E2 and E3 did not complete emergency safety ...