New Hope Of Arizona

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

Based on documentation review and interview, the administrator failed to ensure sufficient personnel members were present on the behavioral health residential facility's premises to ensure the health and safety of a resident. The deficient practice posed a health and safety risk as residents under the age of 18 were left unsupervised. 1. A review of the facilities documentation revealed a staff schedule dated for March 15, 2026 to March 21, 2026. The schedule reflected three shifts are maintained daily; 12:00 AM to 9:00 AM, 2:00 PM to 9:00 PM, and 9:00 PM to 12:00 AM. The schedule revealed E2 to be the only personnel on site on March 18, 2026, from 12:00 AM to 9:00 AM. 2. A review of the facilities documentation revealed a document titled "Youth Incident Report" dated March 18, 2026. The incident report stated, "At 7:40 AM...[R1] became upset and ran out the door...[E2] witnessed [R1] leave out the door and [E2] began to follow as far as possible before not being able to see [R1]." The incident report indicated R1 was without facility staff supervision from 7:40 AM to 9:08 AM. 3. In an interview, E1 reported there being a "couple" of residents at the facility during the time of the AWOL; however, no exact count was given. 4. In an interview, E1 reported that a Child and Family Team meeting (CFT) would be held for R1 to refer R1 to a higher level of care facility. The reasoning E1 reported was R1 is no longer meeting the facility's scope of services due to the incident. 5. In ...

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

Based on documentation review and interview, the administrator failed to ensure continuous protective oversight was provided to residents under the age of 18. The deficient practice posed a health and safety risk as vulnerable residents who required continuous protective oversight were left unsupervised. 1. A review of facility documentation revealed a staff schedule for March 15, 2026, to March 21, 2026. The schedule reflected three shifts are maintained daily: 12:00 AM to 9:00 AM, 2:00 PM to 9:00 PM, and 9:00 PM to 12:00 AM. The schedule revealed E2 to be the only personnel on site on March 18, 2026, from 12:00 AM to 9:00 AM. 2. A review of facility documentation revealed a document titled "Youth Incident Report" dated March 18, 2026. The incident report stated, "At 7:40 AM...[R1] became upset and ran out the door...[E2] witnessed [R1] leave out the door and [E2] began to follow as far as possible before not being able to see [R1]...[E2] gathered all members (and) notified PD." The incident report indicated R1 was without facility staff supervision from 7:40 AM to 9:08 AM. 3. In an interview, E1 reported there being a "couple" of residents at the facility during the time of the AWOL; however, no exact count was given. 4. A review of R1's medical record revealed a document titled "Comprehensive Assessment" dated February 2026. The assessment did not indicate R1 had previous behaviors of unauthorized absences at previous placements. 5. In an interview, E1 reported that a ...

Deficiency cited, complaint : R9-10-716.D.2.a.i-v. Behavioral Health Services D. An administrator of a behavioral health residential facility authorized to provide behavioral health ...

Based on record review and interview, the administrator failed to ensure that a resident did not receive ridicule, verbal harassment, punishment, or abuse from other residents at the behavioral health residential facility. The deficient practice posed a risk to residents as R4 was physically aggressive towards other residents. 1. A review of R4's medical record revealed a behavioral health assessment completed in August 2025. The assessment revealed R4 had a history of physical abuse. In addition, R1 had a history of being physically aggressive and a history of self-harm. 2. A review of R4's medical record revealed an incident report dated September 29, 2025. The incident report stated, “Staff directed the member to sit in the back of the vehicle. The member declined and responded with verbal aggression and cursing shortly after, another member placed a hand near the member's face, at which point [R4] slapped the member, resulting in a bloody nose.” 3.In an interview, E1 acknowledged the personal history of R4. E1 acknowledged the incident on September 29, 2025, resulting in R4 becoming physically aggressive with another resident, resulting in an injury. E1 acknowledged that the administrator failed to ensure that a resident did not receive ridicule, verbal harassment, punishment, or abuse from other residents at the behavioral health residential facility.

Deficiency cited, compliance (annual) : A. An administrator shall ensure that: 7. A resident does not: a. Use or have access to any materials, furnishings, or equipment or participate in any activity ...

Based on documentation review, record review, and interview, the administrator failed to ensure a resident did not have access to any materials, furnishings, or equipment or participate in any activity to present a threat to the resident's health or safety based on the resident's documented diagnosis, treatment needs, or personal history. The deficient practice posed a risk as residents had access to materials while admitted into a behavioral health residential facility. 1. A review of the facilities policies and procedures revealed a policy titled "Contraband Search." The policy stated "...To ensure the safety of the clients/consumers, visitors and staff members: Upon entering the facility each client/ consumer shall be checked: 1. Pockets turned inside out, pant cuffs are turned up...." 2. A review of R2's medical record revealed a document titled "Incident Report" dated September 22, 2024. The report stated "Another member at respite informed DPS that [R2] had a vape pen in [R2] pocket. DPS confiscated Vape from [R2]." 3. In phone interview, E6 reported E6 was notified by another resident R2 had a vape pen at the residential facility. E6 reported E6 did a search of R2's personal bag at arrival. However, E6 reported no additional searches were conducted to include pockets turned inside out. E6 acknowledged R2 had access to a vape pen at the behavioral health residential facility.