Devereux Arizona

Deficiency cited, complaint : 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, documentation 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 two medical records sampled. The deficient practice posed a risk if R2 experienced a change in condition due to improper assistance in the self-administration of medication. 1. A review of R2's medical record revealed a medication order for "Clonidine 0.1mg, 1 tab PO HS". 2. A review of R2's medical record revealed a medication administration record (MAR) dated November 2025. The MAR revealed R2 did not receive assistance in the self-administration for "Clonidine 0.1 MG" on November 17, 2025. 3. A review of facility documentation revealed a document titled "Medical Event Documentation" dated November 18, 2026. The document stated, "...Medication Event Medication Event Type: Dose Omitted Start Date: 11/17/2025 End Date: 11/17/2025...Description of Medication Event to include Medications(s), dose(s), route(s), and times(s) related to medication event type(s): Individual was not given clonidine 0.2mg at 8:00pm. staff [staff name] made a med error Medication error cause: Other Please indicate: Dose omitted Responsible party for medication event: Devereux Staff." 4. A review of facility documentation revealed a policy titled "Medication Services, Definitions, and Training - Procedure No. 208" dated June 24, 2026. The policy stated, "...II. Purpose...Devereux Arizona ...

Deficiency cited, complaint : R9-10-718.B.3.a-b. Medication Services B. If a behavioral health residential facility provides medication administration, an administrator shall ensure that ...

Based on documentation review, record review, and interview, the administrator failed to ensure medication administration was provided to a resident in compliance with an order, for one of five residents sampled. The deficient practice posed a risk if R2 experienced a change in condition due to improper medication administration, and the repeated violation shows a pattern of non-compliance to ensure the health and safety of residents. 1. A review of facility documentation revealed a scope of services titled “Program Model: Assessment and Intervention Center (AIC)” (dated October 2024). However, the scope of services did not include whether assistance in the self-administration of medication or medication administration was provided. 2. A review of facility documentation revealed a policy and procedure titled "Medical Services, Medication Administration and Training" (dated October 28, 2022). The policy and procedure stated " ... III. Definition(s) I. Medication Administration: Securing the patients medication and providing the medication to the patient or applying the medication to the patient’s body as ordered by a medical practitioner. II. Assistance in the Self Administration of Medication: Restricting a patient’s access to the patient’s medication, and providing support to the patient, while the patient takes the medication to ensure that the medication is taken as ordered.” However, the policy and procedure did not include assistance in the self-administration of ...

Deficiency cited, complaint : R9-10-708.A.5. Treatment Plan A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that: 5. If the treatment ...

Based on record review, documentation review, and interview, the administrator failed to ensure a treatment plan completed by a behavioral health technician (BHT) was reviewed and signed by a behavioral health professional (BHP) within 24 hours after the completion of the treatment plan, for three of six residents sampled. The deficient practice posed a risk as the treatment plan was reviewed and approved by a behavioral health professional who was not certified or licensed to provide the behavioral health services needed by the resident. Arizona Revised Statute (A.R.S.) § 32-2091(3) "Behavior analysis" means the design, implementation and evaluation of systematic environmental modifications by a behavior analyst to produce socially significant improvements in human behavior based on the principles of behavior identified through the experimental analysis of behavior. Behavior analysis does not include cognitive therapies or psychological testing, neuropsychology, psychotherapy, sex therapy, psychoanalysis, hypnotherapy and long-term counseling as treatment modalities. A.R.S. § 32-2091(5) "Behavior analyst" means a person who is licensed pursuant to this article to practice behavior analysis A.R.S. § 32-3251(9) "Practice of behavioral health" means the practice of marriage and family therapy, practice of professional counseling, practice of social work and practice of addiction counseling pursuant to this chapter. A.R.S. § 36-401(11) "Behavioral health services" means ...

Deficiency cited, complaint : R9-10-718.B.3.a-b. Medication Services B. If a behavioral health residential facility provides medication administration, an administrator shall ensure that ...

Based on documentation review, record review, and interview, the administrator failed to ensure medication administration was provided to a resident in compliance with an order. The deficient practice posed a risk if R2 and R3 experienced a change in condition due to improper medication administration. 1. A review of facility documentation revealed a scope of services titled “Program Description Devereux Assessment and Intervention (dated October 2024). However, the scope of services did not include whether assistance in the self-administration of medication or medication administration was provided. 2. In an interview, E1 reported assistance in the self-administration of medication was provided. E1 later reported BHTs provide medication administration as BHTs punch out the medications from the pharmacy-provided multi-dose packaging, place them into a cup, and give to residents. 3. A review of facility documentation revealed a policy and procedure titled "Medical Services, Medication Administration and Training" (dated October 28, 2022). The policy and procedure stated " ... III. Definition(s) I. Medication Administration: Securing the patients medication and providing the medication to the patient or applying the medication to the patient’s body as ordered by a medical practitioner. II. Assistance in the Self Administration of Medication: Restricting a patient’s access to the patient’s medication, and providing support to the patient, while the patient takes the medication ...

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

Based on record review, documentation 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 and was documented in the resident's medical record, for four of four resident records sampled. The deficient practice posed a risk to the health and safety of residents if residents did not receive their required medication and a medication error occurred. 1. A review of R1's medical record revealed a medication administration record (MAR) dated in August 2024. The MAR stated, "Buspirone HCL 7.5 MG Tablets... take 2 tablet by mouth daily for anxiety." However, on August 10, 2024, the MAR was blank as the medication was not taken. The back of the MAR included a section for personnel to make notes which was titled "Medication Not Administered (Refused/Missed/Extra/AWOL)," however personnel did not fill out the section for the August 10, 2024. 2. A review of R2's medical record revealed a MAR dated in July 2024. The MAR stated, "Guanfacine 2 MG... take one tablet by mouth 2 times a day at [7:00 AM and 4:00 PM]." However, from July 16, 2024, through July 26, 2024, the MAR revealed the medication was taken at 8:30 AM on July 16, 2024, 8:11 AM on July 17, 2024, 7:56 AM on July 18, 2024, and an average time in between 8:00 AM through 8:30 AM up until July 26, 2024. 3. A review of R2's medical record revealed a MAR dated in August 2024. The MAR stated, "Cetirizine 10 MG... take 1 ...

Deficiency cited, complaint : C. An administrator shall ensure that: 2. Policies and procedures for behavioral health services and physical health services are established, documented, and ...

Based on documentation review and interview, the administrator failed to ensure policies and procedures for behavioral health services were implemented to cover assistance in the self-administration of medication. The deficient practice posed a risk to the health and safety of residents if residents did not receive their required medication and a medication error occurred. 1. A review of facility documentation revealed a policy titled, "Medication Procedure for BHRF Programs." The policy stated, "... ; IV. Procedures:... E. Administration of Medication: 1. Administration of Medication includes: a. The BHRF Individual reports to the trained BHRF staff for medication administration b. BHRF staff verifies the Individual ' s identity by checking at least two identifiers prior to administering medication c. BHRF staff open the medication container and provides the prescribed dosage to the BHRF Individual d. BHRF staff verify that the BHRF Individual takes the medication in accordance with the 5 Rights of Medication Administration. ; G. Medication Administration Record (MAR): 1. Trained BHRF staff verify the MAR is current and accurate 2. The MAR contains the Individual ' s name, the name of the medication, the dosage and directions for taking the medication and the name of the provider or treating physician 3. BHRF staff will document each medication pass with time and initials. Individuals will initial the MAR after medication administration is completed 4. BHRF staff document ...

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

Based on documentation review, record review, and interview, the administrator failed to ensure assistance in the self-administration of medication administered to a resident was in compliance with an order and documented in the resident's medical record, for seven out of eights residents sampled. The deficient practice posed a risk to the health and safety of residents if residents did not receive their required medication and a medication error occurred. 1. A review of facility documentation revealed a policy titled, "Medication Procedure for BHRF Programs." The policy stated, "... E. Administration of Medication: 1. Administration of Medication Includes: a. The BHRF individual reports to the trained BHRF staff for medication administration. b. BHRF staff verifies the individual's identity by checking at least two identifiers prior to administering medication. c. BHRF staff open the medication container and provides the prescribed dosage to the BHRF individual. d. BHRF staff verify that the BHRF individual takes the medication in accordance with the 5 rights of medication administration. e. Staff will encourage individuals to take their medication as ordered and provide medication education as needed. Individual's will not be restrained or forced to take regularly scheduled medications and are to be permitted to refuse medication. Staff will document the refusal in the medication administration record as noted above and notify the nurse on call, who will notify the BHMP ...

Deficiency cited, complaint : B. An administrator shall ensure that counseling is: 1. Offered as described in the behavioral health residential facility's scope of services, 2. Provided ...

Based on documentation review, record review and interview, the administrator failed to ensure the facility's scope of services included a description of how counseling would be offered, and treatment plans included the frequency and number of hours counseling was to be provided, for three of three residents sampled. The deficient practice posed a risk if a resident did not receive treatment to cure, improve, or palliate their behavioral health issue at the health care institution. A.A.C. R9-10-101(36) states, " 36. "Behavioral health residential facility" means a health care institution that provides treatment to an individual experiencing a behavioral health issue that: a. Limits the individual's ability to be independent, or b. Causes the individual to require treatment to maintain or enhance independence." A.A.C. R9-10-101(238) states, "238. "Treatment" means a procedure or method to cure, improve, or palliate an individual's medical condition or behavioral health issue." A.A.C. R9-10-101(200) states, " 200. "Respite services" means respite care services provided to an individual who is receiving behavioral health services." 1. A review of facility documentation revealed an undated policy and procedure titled "Program Model: Facility Based Respite" dated October 20, 2022. The policy and procedure stated, "Purpose Devereux Arizona is committed to providing the least restrictive and most appropriate services to individuals referred for care. Facility Based Respite care is ...

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

Based on documentation review, record review, and interview, the administrator failed to ensure a resident's medical record contained orders, for one of five residents sampled. The deficient practice posed a risk as medication administration could not be verified against a medication order. 1. A review of facility documentation revealed an incident reported dated March 26, 2023. The report stated "Staff [E3] gave individual [R1] two tabs of Prazosin 1 mg instead of one tab Prazosin 1 mg as prescribed." 2. A review of R1's medication administration record (MAR) for the month of March 2023 revealed R1 received medication administration for Prazosin 1 mg on the following dates: March 22-31, 2023. 3. A review of R1's medical record revealed a medication order for Prazosin 1 mg was not available for review. 4. In a joint interview, E4, E5, E6, and E9 acknowledged R1's medical record did not contain a medication order.

Deficiency cited, complaint : B. If a behavioral health residential facility provides medication administration, an administrator shall ensure that: 3. A medication administered to a ...

Based on documentation review, record review, and interview, an administrator failed to ensure medication administered to a resident was administered in compliance with an order, for two of five residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper medication administration. 1. A review of facility documentation revealed an incident report, dated April 13, 2023. The incident report stated "During this reconciliation, staff [E7] discovered that indiv [sic] [R2] Clonidine 0.1 mg was off count. Staff on [E7] checked with staff [E8] DCP, BHT, who had administered the P.M. medication earlier. Staff determined that indiv [sic] [R2] was given Clonidine 0.1 mg half tab and [R2] was prescribed to get Clonidine 0.1 mg whole tab. Staff [E8] gave the half tab based on the medication administration record prepared by nursing which stated "PM- Take- Take 1/2 tablet by mouth'. The instructions on the MAR were incorrect and inconsistent with the medication packaging which read to take a whole tab." 2. A review of R2's medical record revealed a medication order dated April 13, 2023. The order stated "Clonidine 0.1 mg...1 tab PO HS" 3. A review of R2's medication administration record (MAR) for the month of April 2023 revealed two separate MARs for April 2023. The first MAR revealed R2 received medication administration for Clonidine 0.1 mg on the following dates and times: April 13, 2023 during the "PM" timeslot, the MAR ...

Deficiency cited, complaint : F. An administrator shall ensure that a personnel member immediately reports a medication error or a resident's adverse reaction to a medication to the medical ...

Based on record review and interview, the administrator failed to ensure a personnel member immediately reported a medication error to the medical practitioner who ordered or prescribed the medication, for one of two resident records reviewed. A.A.C. R9-10-101(135) "Medication error" means: a. The failure to administer an ordered medication; b. The administration of a medication not ordered; or c. The administration of a medication: i. In an incorrect dosage, ii. More than 60 minutes before or after the ordered time of administration unless ordered to do so, or iii. By an incorrect route of administration. 1. A review of R1's medical record revealed the following medication orders: - "Escitalopram 20mg tablet: take 1 tablet every morning ..."; - "Prazosin 1 mg PO qhs"; and - "Aripiprazole 20 mg Oral Nightly at Bedtime". 2. A review of R1's Medication Administration Record (MAR) dated "January/2023", revealed the following: - Escitalopram 20mg, 1 tablet, was to be provided at "8AM"; - Prazosin 1 mg, 1 capsule, was to be administered at "8PM"; and - Aripiprazole 20 mg, 1 tablet, was to be administered at "8PM". 3. The MAR indicated the following medications were provided more than 60 minutes after the ordered time of administration: - Escitalopram was administered at 9:28AM on January 9, 2023; - Prazosin was administered at 6:53PM on January 9, 2023, and; - Aripiprazole was administered at 6:52PM on January 9, 2023. 4. In an interview E1 acknowledged there was no documentation ...