Zarephath Inc. – Apache House

Deficiency cited, compliance (annual) : R9-10-712.C.9. Medical Records 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 resident records sampled. The deficient practice posed a risk as assistance in the self-administration of medication could not be verified against a medication order, and the repeated violation shows a pattern of noncompliance to ensure the health and safety of residents. 1. A review of R2’s medical record revealed a daily medication administration record (MAR). The MAR revealed R2 was provided the following medications on the following dates and times: -"Sertraline HCL 50 mg" on May 22, 2026 at 8:05 PM and May 23, 2026 at 8:24 PM; -"Clonidine HCL 0.2 mg" on May 22, 2026 at 8:05 PM and May 23, 2026 at 8:24 PM; and -"Amphetamine Salts ER" on May 23, 2026 at 7:51 AM and May 24, at 8:06 AM. 2. A review of R2's medical record revealed no medication orders for the aforementioned medications. 3. In an interview, E1 reported the facility was waiting for R2's guardian to send the medication orders. 4. In an exit interview, the findings were reviewed with E1, and no additional statements or documents were provided. This is a repeated violation from the July 18, 2025 compliance inspection.

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

Based on documentation review and interview, the health care institution failed to develop a training program regarding fall prevention and fall recovery. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not developed. 1. A review of facility documentation revealed no training program for fall prevention and fall recovery. 2. In an interview, E1 reported policies and procedures were developed regarding fall prevention and fall recovery. However, E1 was unable to locate the policies and procedures. 3. In an exit interview, the findings were reviewed with E1, and no additional comments or documentation were provided.

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

Based on documentation review, record review, and interview, the administrator failed to ensure a personnel record was maintained to include documentation of clinical oversight, as required in Arizona Administrative Code (A.A.C.) R9-10-115, for one of one personnel members sampled who provided counseling. The deficient practice posed a risk as a behavioral health technician provided behavioral health services they were not licensed to provide and were without clinical oversight by a licensed behavioral health professional. A.A.C. R9-10-101.49.a.b.c.d. "Clinical oversight" means: Monitoring the behavioral health services provided by a behavioral health technician to ensure that the behavioral health technician is providing the behavioral health services according to the health care institution's policies and procedures and, if applicable, a patient's treatment plan; Providing on-going review of a behavioral health technician's skills and knowledge related to the provision of behavioral health services; Providing guidance to improve a behavioral health technician's skills and knowledge related to the provision of behavioral health services; and Recommending training for a behavioral health technician to improve the behavioral health technician's skills and knowledge related to the provision of behavioral health services. A.A.C. R9-10-115(4) A behavioral health technician receives clinical oversight at least once during each two-week period, if the behavioral health technician ...

Deficiency cited, compliance (annual) : R9-10-706.G.3.j. 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 to include documentation of evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113.A.B., for one of seven personnel members sampled. The deficient practice posed a potential TB exposure risk to residents. R9-10-113(A)(2)(b) states: "If an individual may have a latent tuberculosis infection, as defined in A.A.C. R9-6-1201: Referring the individual for assessment or treatment; and annually obtaining documentation of the individual's freedom from symptoms of infectious tuberculosis, signed by a medical practitioner, occupation health provider, as defined in A.A.C. R9-6-801, or local health agency, as defined in A.A.C. R9-6-101." R9-10-113(B)(1)(a)(i) A health care institution's chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specified in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: a. Documentation of a negative Mantoux skin test or other tuberculosis screening test that: i. Is recommended by the U.S. Centers for Disease Control and Prevention (CDC), 1. A review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the ...

Deficiency cited, 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 shall ensure a treatment plan was developed and implemented for each resident based on the nursing assessment required in R9-10-707(A)(6) or (E)(1)(a) for two of two medical records sampled. The deficient practice posed a risk as a treatment plan was not developed to articulate decisions and agreements based on the medical history and physical examination or nursing assessment. A.R.S. § 36-425.08(A) A behavioral health residential facility may provide respite care to a child for increments of fewer than five consecutive days and not more than twelve days in a ninety-day period or an outpatient clinic may provide respite care to a child for up to ten continuous hours per day between the hours of 6:00 a.m. and 10:00 p.m. without a medical history and physical examination. 1. A review of R1's (last admitted in 2025) electronic medical record revealed a treatment plan dated in December 2024. However, a review of R1's electronic medical record revealed no documentation of a nursing assessment required in R9-10-707(A)(6) or (E)(1)(a), and therefore, the treatment plan was not based on the nursing assessment. 2. A review of R2's (last admitted in 2025) electronic medical record revealed a treatment plan dated in January 2025. However, a review of R2's electronic medical record revealed no documentation of a nursing assessment required in R9-10-707(A)(6) or (E)(1)(a), and therefore, the treatment plan was not based on the ...

Deficiency cited, compliance (annual) : R9-10-712.C.9. Medical Records 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 two of two medical records sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper assistance in the self-administration of medication. 1. A review of R1's and R2's (last admitted in 2025) electronic medical records revealed no documentation of medication orders. 2. A review of R1's electronic medical record revealed a medication administration record dated in March 2025 for the following medication: -"Amphetam / Dextoamp ER 10mg 1 capsule @ 8 am." However, E1's electronic record revealed no documentation of medication orders. 3. A review of R2's electronic medical record revealed a medication administration record dated in March 2025 for the following medications: -"Clonidine HCL .1mg tab 2 tabs @ 8 pm;" and -"Atomoxetine HCL 18 mg cap 1 cap @ 8 am." However, R2's electronic record revealed no documentation of medication orders. 4. In an interview, E1 reported E1 has requested the signed medication orders in the past but had not received the orders. 5. In an exit interview, the findings were reviewed with E1, and no additional comments or documentation were provided.

Deficiency cited, compliance (annual) : R9-10-716.B.2. Behavioral Health Services B. An administrator shall ensure that counseling is: 2. Provided according to the frequency and number of hours ...

Based on record review and interview, the administrator failed to ensure counseling was provided according to the frequency and number of hours identified in the resident's treatment plan, for two of two medical records sampled. The deficient practice posed a risk if a resident did not receive sufficient treatment to cure, improve, or palliate their behavioral health issues. 1. A review of R1's (last admitted in 2025) electronic medical record revealed a treatment plan dated in December 2024. The treatment plan stated "...Group counseling (Respite) (1-6x/Quarter)." However, the treatment plan did not include the number of hours for group therapy to be provided to R1. 2. A review of R2's (last admitted in 2025) electronic medical record revealed a treatment plan dated in January 2025. The treatment plan stated "...Group counseling (Respite) (1-6x/Quarter)." However, the treatment plan did not include the number of hours for group therapy to be provided to R1. 3. In an exit interview, the findings were reviewed with E1, and no additional comments or documentation were provided.