RMBHS

Deficiency cited, 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, a behavioral health residential facility's scope of services to include assistance in the self-administration of medication. 1. A review of R1's medical record revealed the following medication orders: cetirizine 5 mg oral tablet, chewable, one tablet, chew every evening for 30 days as needed for allergy; risperidone 1 mg, by mouth every morning and 1 mg by mouth every evening; Focaline XR 5 mg, by mouth every morning; and Ritalin 5 mg, by mouth every morning. 2. A review of R1's medical record revealed R1 was provided assistance in the self-administration of medication for the following medications: cetirizine 5 mg, give one tablet to chew and swallow in the evening as needed for allergy symptoms, June 6-7, 2025; methylphenidate 5 mg, take one tablet by mouth only in the morning for attention deficit hyperactivity disorder, June 7-8, 2025; Dexmethylphenidate 5 mg, take one capsule by mouth every day in the morning for attention deficit hyperactivity disorder, June 7-8, 2025; and risperidone 1 mg, take one tablet by oral route every morning and at bedtime, June 6-8, 2025. 3. A review of R2's medical record revealed the following medication orders: desmopressin 10 mg mcg/inhaler nasal spray, 30 microgram(s) or three sprays intranasally twice a day; guanfacine ER 2 mg tablet extended release 24 hours, take one tablet by mouth every 8:00 p.m.; and clonidine HCL ...

Deficiency cited, compliance (annual) : R9-10-718.C.4.a. Medication Services C. If a behavioral health residential facility provides assistance in the self-administration of medication, an ...

Based on record review and interview, the administrator failed to ensure training for a personnel member, other than a medical practitioner or registered nurse, in assistance in the self-administration of medication was provided by a medical practitioner or registered nurse or an individual trained by a medical practitioner or registered nurse, for one of three personnel members sampled who provided assistance in the self-administration of medication. The deficient practice posed a risk a resident experienced a change in condition due to improper assistance in the self-administration of medication. 1. A review of E4's personnel record revealed a certificate of completion (dated December 10, 2024). The certificate indicated E4 completed training in the "[Red Mountain Behavioral Health Services] Medication" course. 2. In an interview, E1 reported E4's training was completed online with no demonstration of E4's skills, was not provided by a medical practitioner or registered nurse, or provided by an individual trained by a medical practitioner or registered nurse. E1 confirmed E4 provided assistance in the self-administration of medication as part of E4's job duties. 3. In an exit interview, the findings were discussed with E1, and no additional statements or documentation were provided.

Deficiency cited, 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 able to implement a disaster plan. 1. A review of Department documentation revealed BH5175 had been licensed since July 2017. 2. A review of facility documentation revealed a document titled "Disaster Drill Report" (dated January 17, 2025). However, no documentation of disaster drills for employees conducted on each shift at least once every three months was available. 3. In an interview, E1 reported disaster drills were completed at least once every three months, but acknowledged they were not documented. 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) : 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, 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. R9-10-101.24. "Assistance in the self-administration of medication" means restricting a patient ' s access to the patient ' s medication and providing support to the patient while the patient takes the medication to ensure that the medication is taken as ordered. 1. A review of R2's (admitted in 2022) medical record revealed a treatment plan, last updated in August 2024. The treatment plan revealed R2 received assistance in the self-administration of medication. 2. A review of R2's medication orders (last updated May 26, 2023) revealed R2 was prescribed the following medications: -Buspirone 7.5 mg one tablet twice per day; -Lamictal 150 mg one tablet twice per day; -Lexapro 10 mg one tablet daily; -Lexapro 5 mg one tablet daily; -Quetiapine 100 mg one tablet in the morning; -Quetiapine 400 mg one tablet nightly; -Melatonin 3 mg one tablet every bedtime; and -Metformin 500 mg one and a half tablets in the mornings and evenings with meals. 3. A review of R2's medication administration record for the month of November 2023 revealed R2 was provided assistance in the self-administration of ...