summary: Complaint - 8/7/2024

raw_content: An on-site investigation of complaint AZ00214147 was conducted on August 7, 2024, and the following deficiencies were cited :

rule: 36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition A. Each health care institution shall develop and administer a training program for all staff regarding fall prevention and fall recovery. The training program shall include initial training and continued competency training in fall prevention and fall recovery. A health care institution may use information and training materials from the department's Arizona falls prevention coalition in developing the training program.

evidence: Based on documentation review, record review, and interview, the health care institution failed to 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.

findings: 1. A review of facility documentation revealed a policy titled, " Fall Prevention and Recovery." The policy stated, "... I. PURPOSE: HCSI Home Care provides a safe work environment for employees, residents and visitors; II. POLICY: Our commitment to our employees, residents and visitors is to take every precaution to eliminate the risk of bodily injury due to falls. The fall prevention program is designed and implemented to be an integral part of our safety system. The administrator and staff members will consistently review every department that expose hazards that may present a danger. Administrator is a member of the Arizona Fall Prevention Coalition; III. PROCEDURES: The administrator shall provide oversight on the Fall Prevention and Fall Recovery program. The team shall monitor every department to access for actual or potential hazards that may affect the company's ability to operate safely; a. Each staff member shall be trained in fall prevention techniques and safety procedures; b. All incoming staff will be required to watch a video on YouTube, preventing falls, patient safety; c. Once completed it shall become part of the staff employment record; d. The administrator will look at areas where the staff may need additional training, this training will be completed as needed. Quarterly newsletters will be available for staff members to have resources about falls; e. Educational materials and videos from www.azstopfalls.org will be a part of the ongoing training..." 2. A review of E2's personnel record revealed an initial Relias training in slips, trips, and falls prevention dated January 4, 2024. However, an initial training in fall recovery was not available for review. 3. A review of E3's personnel record revealed documentation of an initial or continued competency training in fall prevention and fall recovery was not available for review. 4. A review of E4's personnel record revealed an initial Relias training in slips, trips, and falls prevention dated November 18, 2023. However, an initial training in fall recovery was not available for review. 5. In an interview, E1 acknowledged the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery.

rule: I. If an administrator has a reasonable basis, according to A.R.S. § 13-3620 or 46-454, to believe abuse, neglect, or exploitation has occurred on the premises or while a resident is receiving services from a behavioral health residential facility's employee or personnel member, the administrator shall: 5. Initiate an investigation of the suspected abuse, neglect, or exploitation and document the following information within five working days after the report required in (I)(2): d. The actions taken by the administrator to prevent the suspected abuse, neglect, or exploitation from occurring in the future; and

evidence: Based on documentation review and interview, the administrator failed to ensure actions taken by the administrator to prevent the suspected abuse, neglect, or exploitation from occurring in the future was documented in the required report. The deficient practice posed a risk to the health and safety of residents.

findings: 1. A review of facility documentation revealed an incident report dated August 4, 2024 at 5:23 PM. The report stated, "... Type of Incident: Unwanted sexual touching, boundaries concern; Hospitalization Required: No; Police Involved: No; Severe AWOL: No; Person Completing Report: [E1]; Date Report Completed: 8/5/2024; Names of Staff Involved: [E2], [E3], [E4]; General Description of Incident: While at the gym, [R1] approached... staff and asked.. staff if [R1] speak with [E2]. Male staff explained that male staff was having a conversation and they could speak after to the female staff, [R1] was visibly agitated.... staff took [R1] upstairs and gave [R1] the opportunity to work out. As clients returned and... [E3] was washing dishes, [R1] approached [E3], began making comments, approached [E3] and began expressing that [R1] likes [E2], and made statements that [R1] was able to brush by [E2's] breast by grabbing [E2's] badge. Staff explained that brushing up against an adult while they are unaware is inappropriate. [R1] agreed that it is not ok to be doing that. [E3] spent time with [R1] explained the importance of boundaries. The following day, staff member [E3] informed [E4] about the statements that were made by [R1] and [E4] decided to have a conversation with [R1] regarding the behaviors. During the conversation [R1] expressed to [E4] that [E2] told [R1] that when [R1] discharges, [E2] and [R1] can be in a relationship and gave [R1] [E2's] number. As staff began to probe on what number [R1] had for [E2], [R1] mentioned that [R1] retracted [R1's] statement and advised that [R1] got [E2's] number from another client. [R1] further asked [E3] and [E4], 'Do you guys think that [E2] likes me?.' [E4] spoke with [R1] about the importance of boundaries and [R1] being in a safe environment. [E1] spoke with [R1] about the allegations, and [R1] explicitly stated that while being transported back to the facility [R1] was able to touch [E2's] breast while being transported to the house. [R1] mentioned that on a return trip to the facility, [R1] informed [E2] that [R1] was nervous, while driving past the park, and [E2] asked [R1] to put [E2's] hands on [R1's] heart. [R1] further stated that [R1] in turn put [R1's] hands on [E2's] heart and was able to touch [E2's] breast while doing so. [E2] has denied all allegations. [E2] advised that [E2] is not aware of any instances of [R1] touching [E2] inappropriately, never had inappropriate verbal exchanges with [R1], and have never given [R1] [E2's] number. [E2] mentioned that [R2] (younger client) is the only client permitted to sit up front with [E2] while being transported, due to [R2's] age and [R1] has always sat in the backseat. [E2] further mentioned that during CFT for other client, [R1's] CASA/CM requested [E2's] number and [E2] provided it during the CFT, and [E2] is not certain if [R1] may have written it down. Our team informed the DCS hotline under case number and also... PD for an investigation to be conducted. As a precaution, [E2] was suspended until investigation is completed; Who Was Notified: DCS, MPD, [R1's] team, DHS; When Notified: 8/5/24; Notified by Whom: HCS Team; Further Action Required: Investigation requested and staff suspension until investigation completed..." However, the administrator did not document the actions taken to prevent the suspected abuse, neglect, or exploitation from occurring in the future. 2. In an interview, E1 reported E2 was suspended with pay until the investigation was completed.

rule: G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes: 3. Documentation of: h. Cardiopulmonary resuscitation training, if required for the individual according to R9-10-703(C)(1)(e);

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure documentation of cardiopulmonary resuscitation (CPR) training was maintained in a personnel record according to R9-10-703(C)(1)(e). The deficient practice posed a risk to the health and safety of residents if staff were unable to ensure appropriate action in an emergency situation.

findings: 1. A review of Department documentation revealed BH8688 was licensed to provide services to individuals younger than 18 years of age. 2. A review of facility documentation revealed a policy titled, " CPR & First Aid Guidelines." The policy stated, "... I. PURPOSE: To specify the certification process and timelines that ensure HCSI Home Care employees are able to respond to residents in crisis situation requiring CPR and First Aid techniques that could save life; II. POLICY: All employees must be trained in CPR and First Aid as part of their continued employment. Resident's health and safety must come first; III. PROCEDURES: Training and certification method: 1. All employees MUST have CPR/First Aid in person skill training before working with a resident at HCSI HOME Care, a requirement for all positions..." 3. A review of E3's personnel record revealed a CPR certificate for adults from the Heart Saver Institute with an expiration date of October 19, 2025. However, a CPR certificate for children or infants was not available for review. 4. A review of E4's personnel record revealed a CPR certificate for adults from the National Health & Safety Association with an expiration date of September 28, 2025. However, a review of the National Health & Safety Association website revealed the course was fully administered online. 5. In an interview, E1 acknowledged the CPR certificates were not in compliance with R9-10-703(C)(1)(e).


state: AZ

facility_name: HUMAN CARE SERVICE II

summary: Complaint;Compliance (Annual) - 6/27/2024

raw_content: An on-site investigation of complaint AZ00212305 was conducted on June 27, 2024 and no deficiencies were cited :

inspection_type: Complaint;Compliance (Annual)


summary: Complaint;Compliance (Annual) - 4/11/2024

raw_content: The following deficiencies were found during the on-site compliance inspection and investigation of complaint AZ00208705 conducted on April 11, 2024:

rule: I. If an administrator has a reasonable basis, according to A.R.S. § 13-3620 or 46-454, to believe abuse, neglect, or exploitation has occurred on the premises or while a resident is receiving services from a behavioral health residential facility's employee or personnel member, the administrator shall: 1. If applicable, take immediate action to stop the suspected abuse, neglect, or exploitation; 2. Report the suspected abuse, neglect, or exploitation of the resident: a. For a resident 18 years of age or older, according to A.R.S. § 46-454; or b. For a resident under 18 years of age, according to A.R.S. § 13-3620; 3. Document: a. The suspected abuse, neglect, or exploitation; b. Any action taken according to subsection (I)(1); and c. The report in subsection (I)(2); 4. Maintain the documentation in subsection (I)(3) for at least 12 months after the date of the report in subsection (I)(2); 5. Initiate an investigation of the suspected abuse, neglect, or exploitation and document the following information within five working days after the report required in (I)(2): a. The dates, times, and description of the suspected abuse, neglect, or exploitation; b. A description of any injury to the resident related to the suspected abuse or neglect and any change to the resident ' s physical, cognitive, functional, or emotional condition; c. The names of witnesses to the suspected abuse, neglect, or exploitation; and d. The actions taken by the administrator to prevent the suspected abuse, neglect, or exploitation from occurring in the future; and 6. Maintain a copy of the documented information required in subsection (I)(5) and any other information obtained during the investigation for at least 12 months after the date the investigation was initiated.

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure if an administrator had a reasonable basis, according to A.R.S. \'a7 13-3620 or 46-454, to believe abuse, neglect, or exploitation occurred on the premises or while a resident was receiving services from a behavioral health residential facility's employee or personnel member, the administrator reported, documented, and initiated an investigation of the suspected abuse. The deficient practice posed a risk to resident safety as E2 failed to report the incident that occurred on April 4, 2024, involving R1.

findings: A.R.S. \'a7 13-3620(A) states any person who reasonably believes that a minor is or has been the victim of physical injury, abuse, child abuse, a reportable offense or neglect that appears to have been inflicted on the minor by other than accidental means or that is not explained by the available medical history as being accidental in nature or who reasonably believes there has been a denial or deprivation of necessary medical treatment or surgical care or nourishment with the intent to cause or allow the death of an infant who is protected under section 36-2281 shall immediately report or cause reports to be made of this information to a peace officer, to the department of child safety. 1. A review of the facility's policies and procedures dated in 2023, stated "All employees and volunteers will immediately report to the facility administrator any suspected abuse, neglect, or exploitation of the resident. If abuse, neglect, or exploitation of a resident is alleged or suspected to have occurred before the resident was accepted or while the resident is not on the premises and not receiving services from the facility, the administrator shall immediately report or cause reports to be made to a peace officer or to a protective services worker and report to the legal guardian if resident has one. The above reports shall be made immediately in person or by telephone and shall be followed by a written report mailed or delivered within forty-eight hours or on the next working day if the forty-eight hours expire on a weekend or holiday." 2. In an interview, R1 reported R1 believed E2 had "elbowed" R1 on purpose. 3. A review of facility documentation revealed a witness statement from a school staff member dated May 5, 2024 from O2, which stated: "On April 5, 2024 at approximately 2:35 PM, an employee of the group home stopped abruptly at the security door of the school with [R1]. When [E2] stopped [E2] tensed [E2's] stance and extended [E2's] elbow, then proceeded to push [E2's] elbow into [R1's] torso. The employee [E2] and [R1] then both engaged in a verbal argument walking out the door. I then separated them both, keeping [R1] in the building while [E2] walked out... At the car, [R1] entered the vehicle and both [E2] and [R1] continued to engage verbally with each other. At one point, [E2] exited the driver's seat and postured up to [R1]. [R1] then exited the vehicle. As the vehicle moved through the roundabout in front of the office, [R1] opened the door to exit the vehicle. [E2] stopped the vehicle and [R1] exited.... During the incident that occurred on campus [officer] de-escalated [R1's] emotional reactive responses. When [E2] entered the room and spoke with [R1], [E2] argued with and, in my opinion, provoked [R1]." 4. In an interview, E1 was asked if E1 was made aware of the alleged incident between E2 and R1. E1 denied being aware of the incident that took place on April 5, 2024 between E2 and R1. E2 failed to report any incident to E1 until six days after. 5. In a telephonic interview, O1 reported the facility was called to pick up R1 as R1 had been disciplined for skipping class. When E2 arrived at the school to pick up R1, E2 was observed as being "antagonizing" towards R1. O1 reported both R1 and E2 were arguing back and forth with each other. O1 reported at one point E2 argued with R1 saying R1 would fail school for skipping class. R1 responded by commenting R1 would do better. However, O1 reported E2 responded by saying "You're just saying that, you're not going to do better." O1 reported when R1 and E2 got in the van to leave the school, R1 got out of the van as E2 was still arguing with R1. O1 however, was able to calm R1 down and decided to transport R1 back to the facility instead of having E2 transport R1 back to the facility. O1 described E2's behavior as unprofessional and unnecessary as it appeared E2 was trying to agitate R1 more than R1 was already agitated. O1 reported while walking out of the school, down the sidewalk, R1 was walking behind E2. "E2 stopped walking and stiffened his body, mostly E2's arm, stuck out his elbow and E2's elbow hit R1. When R1 stated that E2 elbowed R1, E2 denied elbowing R1 and said that if E2 did, it was not intentional. O1 reported O1's body camera was on. O1 stated that E2 did intentionally elbow R1. O1 reported there were no injuries, marks, or bruises observed. O1 reported R1 was becoming more annoyed. It was also observed that E2 took R1's backpack. When R1 asked E2 to give back the backpack, E2 told R1, "No, you're not getting it back. You don't own anything. Everything is mine." R1 stated that E2 always acts this way and stated "E2 also threatens that E2 is going to beat our butts or beat us up." 6. In an interview, R1 corroborated O1's account of the incident between R1 and E2. 7. In an interview, E2 reported E2 did not intentionally "elbow" R1 but rather felt R1 was "in E2's space" and used E2's elbow to create space between E2 and R1, which R1 ran into. 8. In an interview, E1 acknowledged the suspected abuse was not properly reported or investigated as per R9-10-703.I.1-6 and according to the facility policies and procedures as E1 reported not being made aware of the incident by E2 until six days after the incident occurred. This is a repeat deficiency from an complaint investigation conducted on October 31, 2023.

rule: B. An administrator shall ensure that: 1. A resident is treated with dignity, respect, and consideration;

evidence: Based on documentation review and interview, the administrator failed to ensure a resident was treated with dignity, respect, and consideration. The deficient practice posed a risk to the safety of R1 if E2 did not have the ability to deal with at risk youth and maladaptive behaviors. Therefore, failing to uphold resident rights.

findings: 1. A review of facility documentation revealed a document titled "Incident Documentation" created by O2, which stated, "On April 5, 2024 at approximately 2:35 PM, an employee of the group home stopped abruptly at the security door of the school with [R1]. When [E2] stopped [E2] tensed [E2's] stance and extended [E2's] elbow, then proceeded to push [E2's] elbow into [R1's] torso. The employee [E2] and [R1] then both engaged in a verbal argument walking out the door. I then separated them both, keeping [R1] in the building while [E2] walked out... At the car, [R1] entered the vehicle and both [E2] and [R1] continued to engage verbally with each other. At one point, [E2] exited the driver's seat and postured up to [R1]. [R1] then exited the vehicle. As the vehicle moved through the roundabout in front of the office, [R1] opened the door to exit the vehicle. [E2] stopped the vehicle and [R1] exited.... During the incident that occurred on campus [officer] de-escalated [R1's] emotional reactive responses. When [E2] entered the room and spoke with [R1], [E2] argued with and, in my opinion, provoked [R1]." 2. In a telephonic interview, [O1] reported the facility was called to pick up [R1] as [R1] had been disciplined for skipping class. When [E2] arrived at the school to pick up [R1], [E2] was observed as being "antagonizing" towards [R1]. [O1] reported both [R1] and [E2] were arguing back and forth with each other. [O1] reported that at one point [E2] argued with [R1] telling [R1] would fail school for skipping class. [R1] responded by stating [R1] would do better. However, [O1] reports [E2] responded by saying "You're just saying that, you're not going to do better." [O1] reported when [R1] and [E2] got in the van to leave the school towards the facility, [R1] got off the van as [E2] was still arguing with [R1]. [O1] however, was able to calm [R1] down and decided to transported [R1] back to the facility instead of having [E2] transport [R1] back to the facility. [O1] described [E2's] behavior as unprofessional and unnecessary as it appeared [E2] was trying to agitate [R1] more than what [R1] was already agitated. [O1] reports while walking out of the school, down the sidewalk, [R1] was walking behind [E2]. "[E2] stopped walking and stiffened [E2's] body, mostly [E2's] arm, stuck out [E2's] elbow and [E2's] elbow hit [R1]. When [R1] stated that [E2] elbowed [R1], [E2] denied elbowing [R1] and said that if [E2] did, it was not intentional. [O1] reported [O1's] body camera was on. [O1] stated that [E2] did intentionally elbow [R1]. [O1] reported there were no injuries, marks, or bruises observed. [O1] reported [R1] was becoming more annoyed. It was also observed that [E2] took [R1's] backpack. When [R1] asked [E2] to give back the backpack, [E2] told [R1], "No, you're not getting it back. You don't own anything. Everything is mine." [R1] stated that [E2] always acts this way and stated "[E2] also threatens that [E2] is going to beat our butts or beat us up." 3. In an interview, R1 reported R1 believed E2 had "elbowed" R1 on purpose. 4. In an interview, E2 reported E2 did not intentionally "elbow" R1 but rather felt R1 was "in E2's space" and used E2's elbow to create space between E2 and R1, which R1 ran into. 5. In an interview, E1 acknowledged R1 was not treated with dignity, respect, and consideration. This is a repeat deficiency from a complaint investigation conducted on October 31, 2023.


summary: Complaint - 10/31/2023

raw_content: An on-site investigation of complaint AZ00202515, AZ00202557, and AZ00202220 was conducted on October 31, 2023 and the following deficiencies were cited :

inspection_type: Complaint

evidence: Based on documentation review and interview, the administrator failed to ensure if an administrator had a reasonable basis, according to A.R.S. \'a7 13-3620, to believe abuse, neglect, or exploitation occurred on the premises or while a resident was receiving services from a behavioral health residential facility's employee or personnel member, the administrator took immediate action to stop the suspected abuse, neglect, or exploitation; reported the suspected abuse, neglect, or exploitation of the resident according to A.R.S. \'a7 13-3620; documented the suspected abuse, neglect, or exploitation, any action taken according to subsection (I)(1), and the report in subsection (I)(2); maintained the documentation in subsection (I)(3) for at least 12 months after the date of the report in subsection (I)(2); initiated an investigation of the suspected abuse, neglect, or exploitation and documented the following information within five working days after the report required in (I)(2): a. The dates, times, and description of the suspected abuse, neglect, or exploitation; b. A description of any injury to the resident related to the suspected abuse or neglect and any change to the resident's physical, cognitive, functional, or emotional condition; c. The names of witnesses to the suspected abuse, neglect, or exploitation; and, d. The actions taken by the administrator to prevent the suspected abuse, neglect, or exploitation from occurring in the future; and maintain a copy of the documented information required in subsection (I)(5) and any other information obtained during the investigation for at least 12 months after the date the investigation was initiated. The deficient practice posed a risk to resident safety, if allegations of abuse were made to staff but staff failed to take measures to ensure resident safety.

findings: A.R.S. \'a7 13-3620(A) states any person who reasonably believes that a minor is or has been the victim of physical injury, abuse, child abuse, a reportable offense or neglect that appears to have been inflicted on the minor by other than accidental means or that is not explained by the available medical history as being accidental in nature or who reasonably believes there has been a denial or deprivation of necessary medical treatment or surgical care or nourishment with the intent to cause or allow the death of an infant who is protected under section 36-2281 shall immediately report or cause reports to be made of this information to a peace officer, to the department of child safety or to a tribal law enforcement or social services agency for any Indian minor who resides on an Indian reservation, except if the report concerns a person who does not have care, custody or control of the minor, the report shall be made to a peace officer only... 1. A review of the facility's policies and procedures dated in 2023, stated "All employees and volunteers will immediately report to the facility administrator any suspected abuse, neglect, or exploitation of the resident. If abuse, neglect, or exploitation of a resident is alleged or suspected to have occurred before the resident was accepted or while the resident is not on the premises and not receiving services from the facility, the administrator shall immediately report or cause reports to be made to a peace officer or to a protective services worker and report to the legal guardian if resident has one. The above reports shall be made immediately in person or by telephone and shall be followed by a written report mailed or delivered within forty-eight hours or on the next working day if the forty-eight hours expire on a weekend or holiday." 2. In an interview, E2 reported being aware of sexual misconduct allegations R1 was making which involved sexual misconduct towards R1 by another resident in October 2021. E2 reported to have written incident reports on "two or three" occasions about R1's unwanted sexual misconduct behavior allegations by another resident towards R1. E2 reported not recalling specific dates when the allegations were made to E2 by R1. 3. A review of the facility's incident reports in October 2021, involving allegations of sexual misconduct by another resident towards R1, were not available for review, as the reports did not exist. 4. In an interview, E1 reported not having knowledge of R1's sexual misconduct allegations by another resident until R1 had been discharged. E1 reported E1 was not informed of the allegations in a timely manner. E1 acknowledged no reports were made according to R9-10-703 (I) (1-6), and no investigation was conducted on the allegations.

evidence: Based on interview and documentaion review, the administrator failed to ensure that a resident was treated with dignity, respect, and consideration, for one resident sampled. The deficient practice posed a risk to the safety of R1 if allegations of sexual misconduct were reported to staff and staff failed to ensure safety. Therefore, failing to uphold resident rights.

findings: 1. In an interview, E2 reported being aware of allegations R1 made, involving sexual misconduct towards R1 by another resident. E2 reported to have written incident reports on "two or three" occasions regarding R1's unwanted sexual misconduct behavior allegations by another resident towards R1. E2 reported not recalling specific dates when the allegations were made to E2 by R1. 2. A review of the facility's incident reports in October 2021, involving allegations of sexual misconduct by another resident towards R1, were not available for review, as the reports did not exist. 3. In an interview, E1 and E2 acknowledged R1 was not treated with dignity, respect, and consideration.

rule: A. An administrator shall ensure that: 2. If a behavioral health residential facility is 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 receives: b. Continuous protective oversight;

evidence: Based on interview and documentation review, 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 the health and safety of an individual under the age of 18, who required continuous protective oversight. Finding include: 1. In an interview, E2 reported being aware of the allegations R1 had made, involving sexual misconduct towards R1 by another resident. E2 reported to have written incident reports on "two or three" occasions regarding R1's unwanted sexual misconduct behavior allegations by another resident towards R1. E2 reported not recalling specific dates when the allegations were made to E2 by R1. 2. A review of the facility's incident reports in October 2021, involving allegations of sexual misconduct by another resident towards R1, were not available for review, as the reports did not exist. 3. In an interview, E1 and E2 acknowledged R1 required continuous protective oversight. E1 and E2 acknowledged R1 did not receive continuous protective oversight.


summary: Complaint - 10/12/2023

raw_content: An on-site investigation of complaint AZ00201763 was conducted on October 12, 2023 and no deficiencies were cited:


summary: Complaint - 10/4/2023

raw_content: An on-site investigation of complaint AZ00199581 was conducted on October 4, 2023 and the following deficiencies were cited :

evidence: 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 health and safety of R1, who required continuous protective oversight. Findings: Finding include: 1. A review of the facility's documentation, revealed a document titled "Incident Report Form" written August 18 23, 2023. The incident report involved R1 taking a trip to a local store with staff. While there, R1 stole six mini bottles of "Fireball", an alcoholic beverage. In turn, R1 became intoxicated and had to be transported to the local hospital for assessment. 2. A review of R1's medical record, revealed diagnosis' as follows: - Disruptive Mood Dysregulation Disorder - Sedative, Hypnotic, or Anxiolytic Use Disorder - Generalized Anxiety Disorder - Cannabis Use Disorder 3. In an interview, E1 acknowledged R1's disorders, and acknowledged personnel failed to ensure the health and safety of R1 due to lack of supervision, which triggered R1 by being around substances that would cause R1 to re-lapse. 4. In an interview, E1 acknowledged, as a result, R1 ingested alcohol, which caused R1 to be under the influence, where R1 was transported to the hospital for a medical assessment.

rule: 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 or treatment that may present a threat to the resident's health or safety based on the resident's documented diagnosis, treatment needs, developmental levels, social skills, verbal skills, or personal history; or

evidence: Based on, documentation review, record review, and interview, the administrator failed to ensure a resident did not use or have access to any materials, or participate in any activity to present a threat to the resident's health or safety based on the resident's documented diagnosis, or personal history. The deficient practice posed a risk as residents consumed alcohol while admitted into a behavioral health residential facility in contradiction with their behavioral health issue.

findings: 1. A review of the facility's documentation, revealed a document titled "Incident Report Form" written August 18 23, 2023. The incident report involved R1 taking a trip to a local store with staff. While there, R1 stole six mini bottles of "Fireball", an alcoholic beverage. In turn, R1 became intoxicated and had to be transported to the local hospital for assessment. 2. A review of R1's medical record, revealed diagnosis' as follows: -Disruptive Mood Dysregulation Disorder -Sedative, Hypnotic, or Anxiolytic Use Disorder -Generalized Anxiety Disorder -Cannabis Use Disorder 3. In an interview, E1 acknowledged R1's disorders, and acknowledged personnel failed to ensure the health and safety of R1 due to lack of supervision, which triggered R1 by being around substances that would cause R1 to re-lapse. 4. In an interview, E1 acknowledged, as a result, R1 ingested alcohol, which caused R1 to be under the influence, where R1 was transported to the hospital for a medical assessment.


summary: Initial Monitoring - 8/15/2023

raw_content: No deficiencies were found during the on-site abbreviated follow-up inspection conducted on August 15, 2023.

inspection_type: Initial Monitoring


summary: Compliance (Initial) - 6/27/2023 - 6/28/2023

raw_content: No deficiencies were found during the on-site initial inspection conducted on June 27, 2023 and the off-site documentation review completed on June 28, 2023.

inspection_type: Compliance (Initial)


facility_name: HEART OF GOLD GROUP HOME LLC

summary: Complaint - 4/15/2025

raw_content: An on-site investigation of complaint 00124956 was conducted on April 15, 2025, and the following deficiencies were cited:

rule: R9-10-705.1-2. Contracted Services An administrator shall ensure that: 1. Contracted services are provided according to the requirements in this Article, and 2. Documentation of current contracted services is maintained that includes a description of the contracted services provided.

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure documentation of current contracted services was maintained, to include a description of the contracted services provided for one registered nurse sampled.

findings: 1. A review of the facility policies and procedures dated 2023, under “Contracted Services R9-10-705,” stated, "The Administrator shall be responsible for ensuring there is a detailed description of services being provided." 2. A review of E3's personnel record, hired as a Registered Nurse (RN), revealed no documentation of current contracted services. 3. In an exit interview, E1 reported a contract for E3 was not maintained. E1 reported E1 would ensure a contract for E3 was drafted immediately.

rule: R9-10-706.G.3.f. Personnel G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes: 3. Documentation of: f. The individual ' s compliance with the requirements in A.R.S. § 8-804, if applicable;

evidence: Based on documentation review, record review and interview, the administrator failed to ensure a personnel record was maintained for each personnel member, employee, volunteer, or student, which included documentation of the individual's compliance with the requirements in A.R.S. § 8-804, if applicable, for four of five personnel records sampled. The deficient practice posed a safety risk to residents if DCS registry background checks were not completed prior to working with residents under the age of 18.

findings: A.R.S. § 8-804(C) "Licensees that do not contract with the state and that employ persons who provide direct services to children pursuant to title 36, chapter 7.1 must submit to the department of child safety in a manner prescribed by the department of child safety information necessary to conduct central registry background checks. The department of health services shall verify whether licensees, pursuant to title 36, chapter 7.1, have complied with the requirements of this subsection and any rules adopted by the department of health services to implement this subsection." A.R.S. § 8-804(J) "Before being employed in a position that provides direct services to children or vulnerable adults pursuant to subsection B, paragraphs 4, 5 and 10 and 11 or subsections C and D and E of this section, employees shall certify, under penalty of perjury, on forms that are provided by the department whether an allegation of abuse or neglect was made against them and was substantiated. The forms are confidential. If this certification does not indicate a current investigation or a substantiated report of abuse or neglect, the employee may provide direct services pending the findings of the central registry check." 1. A review of E1's personnel record revealed E1 was hired as a behavioral health technician in 2022. E1's personnel record revealed no documentation demonstrating the licensee submitted to the Department of Child Safety in a manner prescribed by the Department of Child Safety, which was information necessary to conduct a central registry background check on E1. 2. A review of E2's personnel record revealed E2 was hired as a behavioral health professional in 2024. E2's personnel record revealed no documentation demonstrating the licensee submitted to the Department of Child Safety in a manner prescribed by the Department of Child Safety, which was information necessary to conduct a central registry background check on E2. 3. A review of E3's personnel record revealed E3 was hired as a registered nurse in 2023. E3's personnel record revealed no documentation demonstrating the licensee submitted to the Department of Child Safety in a manner prescribed by the Department of Child Safety, which was information necessary to conduct a central registry background check on E3. 4. A review of E4's personnel record revealed E4 was hired as a behavioral health technician in 2023. E4's personnel record revealed no documentation demonstrating the licensee submitted to the Department of Child Safety in a manner prescribed by the Department of Child Safety, which was information necessary to conduct a central registry background check on E4. 5. In an exit interview, E1 reported being aware E1's, E2's, E3's, and E4's personnel records were not in compliance as per R9-10-706.G.3.f. and A.R.S. § 8-804.

rule: 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 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;

evidence: Based on 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 for four of four residents records sampled.

findings: 1. A review of R1's, R3's, and R4's (admitted in 2024) and R2's (admitted in 2025) medical records revealed no evidence a medical practitioner performed a medical history and physical examination or evidence a registered nurse performed a nursing assessment on R1, R2, R3, and R4 within 30 calendar days before admission or within 72 hours after admission. 2. In an exit interview, E1 reported not being aware of the rule requirements.

rule: R9-10-707.A.13.a. Admission; Assessment A. An administrator shall ensure that: 13. Except as provided in subsection (E)(1)(d), a resident provides evidence of freedom from infectious tuberculosis: a. Before or within seven calendar days after the resident's admission, and

evidence: Based on record review and interview, the administrator failed to ensure a resident provided evidence of freedom from infectious tuberculosis before or within seven calendar days after a resident's admission, for four of four resident records sampled. The deficient practice posed a risk of infection to residents.

findings: 1. A review of R1's, R3's, and R4's (admitted in 2024) and R2's (admitted in 2025) medical records revealed no evidence of freedom from infectious tuberculosis before or within seven calendar days after R1's, R2's, R3's, and R4's admission. 2. In an exit interview, the findings were reviewed with E1. E1 reported not being aware residents required TB testing upon admission.

rule: 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 plan was completed by a behavioral health technician, is reviewed and signed by a behavioral health professional within 24 hours after the completion of the treatment plan to ensure that the treatment plan is complete and accurate and meets the resident's treatment needs; and

evidence: Based on record review and interview, the administrator failed to ensure, If the treatment plan was completed by a behavioral health technician, was reviewed and signed by a behavioral health professional within 24 hours after the completion of the treatment plan to ensure that the treatment plan was complete and accurate and met the resident's treatment needs, for one of four resident records sampled.

findings: 1. A review of R4's medical record revealed a treatment plan dated in 2024 and completed by a BHT. However, the treatment plan was not reviewed and signed by a behavioral health professional within 24 hours after the completion of the treatment plan. 2. In an exit interview, E1 reported being aware R4's treatment plan was not signed by the BHP within 24 hours.

rule: 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 administrator shall ensure that: 4. A disaster drill for employees is conducted on each shift at least once every three months and documented;

evidence: 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 safety risk if personnel were not properly trained on how to respond in the event of a disaster.

findings: 1. A review of the facility policy and procedure dated in 2023 revealed a section titled "Disaster Plan." The policy stated, "A disaster drill for employees is conducted on each shift at least once every three months and documented." 2. The staffing schedule revealed the facility maintained three shifts. The Compliance Officer requested disaster drill documentation for the past 12 months. A review of the facility disaster drills revealed the drills were completed on one out of three shifts on the following dates: -February 2, 2025 at 10:00 AM -March 3, 2025 at 10:00 AM -April 4, 2025 at 10:00 AM 3. In an exit interview, the findings were reviewed with E1. E1 reported not being aware disaster drills were to be completed on each shift.

rule: R9-10-720.B.5. Emergency and Safety Standards B. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 5. An evacuation drill for employees and residents on the premises is conducted at least once every six months on each shift;

evidence: Based on documentation review and interview, the administrator failed to ensure an evacuation drill for employees and residents on the premises was conducted at least once every six months on each shift. The deficient practice posed a health and safety risk to residents if personnel were not properly trained on how to evacuate the facility in the event of an emergency.

findings: 1. A review of the facility policy and procedure dated in 2023 revealed a section titled "Disaster Plan." The policy stated, "An evacuation drill shall be conducted on each shift once every six months." 2. The staffing schedule revealed the facility maintained three shifts. The Compliance Officer requested evacuation drill documentation for the past 12 months. A review of the facility evacuation drills revealed the drills were completed on one out of three shifts on the following dates: -April 4, 2025 at 11:00 AM -March 3, 2025 at 11:00 AM -February 3, 2025 at 11:05 AM -January 3, 2025 at 11:05 AM 3. In an exit interview, the findings were reviewed with E1. E1 reported not being aware evacuation drills were to be completed on each shift.

rule: R9-10-721.A.14. Environmental Standards A. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 14. Poisonous or toxic materials stored by the behavioral health residential facility are maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and are inaccessible to residents;

evidence: Based on documentation review, 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. The deficient practice posed a health and safety risk to residents.

findings: 1. A review of facility policy and procedure revealed a section titled "Environmental Standards", which stated "in order to keep the staff and residents safe, chemicals for laundry and cleaning will be stored in a locked area inaccessible to residents." 2. The Compliance Officer observed an unlocked laundry room in the facility, which contained the following toxic materials accessible to residents: -Three bottles of "Purex" laundry detergent -One bottle of "Gain" laundry detergent 3. In an exit interview, E1 reported laundry was being done, and "normally," chemicals are stored in a locked room.


summary: Compliance (Annual) - 11/20/2024

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on November 20, 2024.

inspection_type: Compliance (Annual)

rule: K. An administrator shall ensure that: 3. There is a daily staffing schedule that: a. Indicates the date, scheduled work hours, and name of each employee assigned to work, including on-call personnel members; b. Includes documentation of the employees who work each calendar day and the hours worked by each employee; and c. Is maintained for at least 12 months after the last date on the documentation;

evidence: Based on documentation review and interview, the administrator failed to ensure there was a daily staffing schedule which indicated the date and on-call personnel members and included documentation of the employees who worked each calendar day. The deficient practice posed a risk as the Department was unable to determine substantial compliance.

findings: 1. A review of facility documentation revealed a daily staffing schedule titled "Week: 1 HEART OF GOLD GROUP HOME STAFF SCHEDULE." The schedule listed all seven days with three shifts per day. The documentation indicated the scheduled working hours and the names of each employee assigned to work. However, the daily staffing schedule did not list the dates, the on-call personnel members, or the employees who worked each day. 2. In an interview, E1 reported this was the facilities current daily staffing schedule. E1 acknowledged the documentation indicated the scheduled working hours and the names of each employee assigned to work. E1 also acknowledged the daily staffing schedule did not list the dates, the on-call personnel members, or the employees who worked each day.

rule: A. An administrator shall ensure that: 7. If a medical practitioner performs a medical history and physical examination or a nurse performs a nursing assessment on a resident before admission, the medical practitioner enters an interval note or the nurse enters a progress note in the resident's medical record within seven calendar days after admission;

evidence: Based on record review and interview, the administrator failed to ensure if a medical practitioner performed a medical history and physical examination or a nurse performed a nursing assessment on a resident before admission, the medical practitioner entered an interval note or the nurse entered a progress note in the resident's medical record within seven calendar days after admission, for two of two resident records sampled. The deficient practice posed a health and safety risk as the Department was unable to determine substantial compliance.

findings: 1. A review of R1's medical record revealed R1 was accepted into the behavioral health residential facility September 2024 with a completed medical history and physical examination. However, documentation of an interval note or progress note in R1's medical record was not established for review. 2. A review of R2's medical record revealed R2 was accepted into the behavioral health residential facility October 2024 with a completed medical history and physical examination. However, documentation of an interval note or progress note in R2's medical record was not established for review. 3. In an interview, E1 acknowledged documentation of an interval note or progress note in R1's and R2's medical records were not established for review. E1 reported R1's and R2's medical histories and physical evaluations were reviewed, but not documented.

rule: A. An administrator shall ensure that: 10. If a behavioral health assessment that complies with the requirements in this Section is received from a behavioral health provider other than the behavioral health residential facility or if the behavioral health residential facility has a medical record for the resident that contains a behavioral health assessment that was completed within 12 months before the date of the resident's current admission: b. The review and update of the resident's assessment information is documented in the resident's medical record within 48 hours after the review is completed;

evidence: Based on record review and interview, the administrator failed to ensure a behavioral health assessment in compliance with the requirements in this Section, received from a behavioral health provider other than the behavioral health residential facility, was reviewed, updated, and documented in the resident's medical record within 48 hours after the review was completed, for two of two residents sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance.

findings: 1. A review of R1's and R2's medical records revealed behavioral health assessments completed within the last twelve months from a behavioral health provider other than BH8884. However, documentation of a review and update of R1's and R2's assessment information was not available for review. 2. In an interview, E1 reported R1's and R2's behavioral health assessments were reviewed by the facility BHP. E1 reported E1 was unaware the review was required to be documented and updated within 48 hours after the review was completed.


summary: Initial Monitoring - 1/26/2024

raw_content: No deficiencies were found during the on-site abbreviated follow-up inspection conducted on January 26, 2024.


summary: Compliance (Initial) - 11/21/2023 - 11/27/2023

raw_content: No deficiencies were found during the on-site initial inspection conducted on November 21, 2023, and the off-site documentation review completed on November 27, 2023.


facility_name: INTERMOUNTAIN CENTERS FOR HUMAN DEVELOPMENT, INC

summary: Complaint - 10/29/2025

raw_content: The following deficiencies were found were found during the on-site  investigation of complaint 00149119 conducted on October 29, 2025:

rule: R9-10-706.B.3.b. Personnel B. An administrator shall ensure that: 3. Sufficient personnel members are present on a behavioral health residential facility's premises with the qualifications, experience, skills, and knowledge necessary to: b. Meet the needs of a resident, and

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure sufficient personnel members were present on a behavioral health residential facility's premises to meet the needs of a resident. The deficient practice posed a risk as the health and safety of residents were at risk with two physical altercations occurring simultaneously on the premises, resulting in injury to residents.

findings: 1. A review of facility documentation revealed incident reports. A incident report dated October 22, 2025 at 8:00 PM revealed a physical altercation between R3 and R4, stating "[R3] pulled a [R4] into [R3] room right before solo leisure, and began throwing punches. [R4] ran out of member's room and into [R4's] room. [R3] went into another peers room and began to assault [peer]. Staff attempted to separate and was on the phone with on call, stepped out of the room and a peer went to try to separate and got kicked. Once separated staff tried to take [R3] off the unit to the other side to keep separated and [R3] rushed peer and staff to try and get to [peer] again. Staff was able to block and ger peer of the unit. [R3] went into the conference room and got on the phone yelling at staff "GET THE [expletive] OTTA HERE [expletive] ! I'm TALKING TO MY PAREENTS!!" [R3]came back out and went to [R3] room and began to punch the wall. [R3] came back out saying to a peer who was in a physical altercation with a different peer "I told you I'd run a fade if you ran a fade." [R3] was laughing and went back to [R3] room. [R3] came back out and stated [R3] needed medical attention. Staff called for all members needing medical attention. [R3] went to [R3] room. [R3] came back out and stated if the cops don't come I'm gonna do it again. Staff reached out to authorities again to update. Staff was told to just keep them separated and they would be here soon. Police and responders came in @ 2135. Assessments of all members involved were done by EMTs and all were cleared unless they wanted to go to the hospital. Authorities placed [R3] in back of their vehicle while waiting for approval to transport to CRC, finished speaking to all parties approximately 2200 and transported member to CRC for evaluation..." 2. A second incident report dated October 22, 2025 at 8:00 PM revealed a physical altercation between R1 and R2, stating, "...[R2] ran into a [R1's] bedroom and began to throw punches and pulling a [R1's] hair. This [R1] is the same peer [R2] was in a physical altercation with the night before... [R2] was escorted out of [R1's] room, but once another physical altercation had taken place between 3 other peers on the unit, and staff was busy getting them to a safe location off the unit, [R2] had gone back into [R1's] room and began throwing [R1's] clothes and belongings all over and tearing things off the walls. [R2] was redirected by another agency staff that responded, to go back to [R2's] room. [R2] walked out of he [R1's] room and was joking with the peer who assaulted other members..." 3. A review of R2's medical record revealed a behavioral health assessment. The behavioral health assessment contained the question, "Does the individual have current or past difficulties with anger management? (i.e. verbally explosive, etc.) [checked Yes] If yes, please elaborate* Member would hit other members when [R2] was angry but "blackout" and not remember doing any of it." and "Did the individual present a risk to themselves and/or others in the past? [checked Yes] Please describe the plan/attempt (Was it impulsive or planned?)* Per member it was impulsive and [R2] would hit others when [R2] was triggered. Per legal guardian, member planned to attack the onsite nurse with other members at [R2] last placement to try to run away. 4. In an interview, E6 reported the incidents started with the physical altercation between R3 and R4. R2 "piggybacked" off of R3 and R4's incident and struck [R1]. [R1] and [R2] were already "butting heads" before the incident. 5. A review of facility documentation revealed policies and procedures. The policy on "Staff to Member Ratio" stated, "During waking hours staff-to-client ratio at Summit is always at a minimum of 1:6. From 7:00 A.M, to 9:00 P.M., the staff-to-client ratio is a minimum of 1:6. From 9:00 P.M. to 7:00 A.M. the (awake at night staff)-to-client ratio is a minimum of 1:10." 6. A review of the daily staffing schedule revealed two behavioral health technicians, one counselor, one supervisor and one AAN staff were scheduled to work on the date of the incident. 7. In an interview, E5 reported the census for the date of the incident was seven at the start of the day and five by the end of the day. An unknown staff member came to assist during the incident for a total of three staff members present during the time of the incidents. E7 started their shift at 9:00 PM at the end of the incidents. E5 reported R3 was a disruptive resident and could not be separated from the residents at all times and was in process of being discharged. R3 was discharged at the time of the investigation. 8. A third incident report dated October 24, 2025 at 4:40 PM stated, "On Friday, October 24, 2025, Member was seen at [emergency department] for a possible injury to [R1] head. Member reported to Staff that [R1] was in a physical fight at ICHD Summit Residential on Tuesday, October 21 as well as Wednesday, October 22. During both fights, Member hit [R1] head a total number of three times: once during the first fight outside on the patio, once in [R1] bedroom on [R1] nightstand, and in [R1] bedroom again on the floor. Today, Member reported the following symptoms: dizziness, headaches, nausea, vomiting, and feeling the need to vomit without being able to. Member was initially seen at [urgent care], but Staff was told to immediately take Member to ED as an MRI could not be performed. Staff was not given an After Visit Summary at [urgent care] after asking; Staff was urged to leave immediately for [hospital]. Member passed the head injury examination at [hospital], so an MRI was not recommended. However, based on [R1] symptoms, Member was diagnosed with Concussion without loss of consciousness. Member was monitored for about an hour, and [R1] was medically cleared after [R1] symptoms did not worsen." 9. In a joint exit interview, the findings were reviewed with E5 and E6 and no additional comments or statements were provided regarding the findings.

rule: 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 treatment, or verbally or physically interact with any other resident that may present a threat to the resident's health or safety, based on the other resident's documented diagnosis, treatment needs, developmental levels, social skills, verbal skills, and personal history.

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a resident does not share any space, participate in any activity or treatment, or verbally or physically interact with any other resident that may present a threat to the resident's health or safety, based on the other resident's documented diagnosis, treatment needs, developmental levels, social skills, verbal skills, and personal history. The deficient practice posed a health and safety risk as residents were injured.

findings: 1. A review of facility documentation revealed incident reports. A incident report dated October 22, 2025 at 8:00 PM revealed a physical altercation between R3 and R4, stating "[R3] pulled a [R4] into [R3] room right before solo leisure, and began throwing punches. [R4] ran out of member's room and into [R4's] room. [R3] went into another peers room and began to assault [peer]. Staff attempted to separate and was on the phone with on call, stepped out of the room and a peer went to try to separate and got kicked. Once separated staff tried to take [R3] off the unit to the other side to keep separated and [R3] rushed peer and staff to try and get to [peer] again. Staff was able to block and ger peer of the unit. [R3] went into the conference room and got on the phone yelling at staff "GET THE [expletive] OTTA HERE [expletive]! I'm TALKING TO MY PAREENTS!!" [R3]came back out and went to [R3] room and began to punch the wall. [R3] came back out saying to a peer who was in a physical altercation with a different peer "I told you I'd run a fade if you ran a fade." [R3] was laughing and went back to [R3] room. [R3] came back out and stated [R3] needed medical attention. Staff called for all members needing medical attention. [R3] went to [R3] room. [R3] came back out and stated if the cops don't come I'm gonna do it again. Staff reached out to authorities again to update. Staff was told to just keep them separated and they would be here soon. Police and responders came in @ 2135. Assessments of all members involved were done by EMTs and all were cleared unless they wanted to go to the hospital. Authorities placed [R3] in back of their vehicle while waiting for approval to transport to CRC, finished speaking to all parties approximately 2200 and transported member to CRC for evaluation..." 2. A second incident report dated October 22, 2025 at 8:00 PM revealed a physical altercation between R1 and R2, stating, "...[R2] ran into a [R1's] bedroom and began to throw punches and pulling a [R1's] hair. This [R1] is the same peer [R2] was in a physical altercation with the night before... [R2] was escorted out of [R1's] room, but once another physical altercation had taken place between 3 other peers on the unit, and staff was busy getting them to a safe location off the unit, [R2] had gone back into [R1's] room and began throwing [R1's] clothes and belongings all over and tearing things off the walls. [R2] was redirected by another agency staff that responded, to go back to [R2's] room. [R2] walked out of he [R1's] room and was joking with the peer who assaulted other members..." 3. A review of R2's medical record revealed a behavioral health assessment. The behavioral health assessment contained the question, "Does the individual have current or past difficulties with anger management? (i.e. verbally explosive, etc.) [checked Yes] If yes, please elaborate* Member would hit other members when [R2] was angry but "blackout" and not remember doing any of it." and "Did the individual present a risk to themselves and/or others in the past? [checked Yes] Please describe the plan/attempt (Was it impulsive or planned?)* Per member it was impulsive and [R2] would hit others when [R2] was triggered. Per legal guardian, member planned to attack the onsite nurse with other members at [R2] last placement to try to run away. 4. In an interview, E6 reported the incidents started with the physical altercation between R3 and R4. R2 "piggybacked" off of R3 and R4's incident and struck [R1]. [R1] and [R2] were already "butting heads" before the incident. 5. A review of facility documentation revealed policies and procedures. The policy on "Staff to Member Ratio" stated, "During waking hours staff-to-client ratio at Summit is always at a minimum of 1:6. From 7:00 A.M, to 9:00 P.M., the staff-to-client ratio is a minimum of 1:6. From 9:00 P.M. to 7:00 A.M. the (awake at night staff)-to-client ratio is a minimum of 1:10." 6. A review of the daily staffing schedule revealed two behavioral health technicians, one counselor, one supervisor and one AAN staff were scheduled to work on the date of the incident. 7. In an interview, E5 reported the census for the date of the incident was seven at the start of the day and five by the end of the day. An unknown staff member came to assist during the incident for a total of three staff members present during the time of the incidents. E7 started their shift at 9:00 PM at the end of the incidents. R3 was a disruptive resident and could not be separated from the residents at all times and was in process of being discharged. R3 was discharged on October 24, 2025. 8. A third incident report dated October 24, 2025 at 4:40 PM stated, "On Friday, October 24, 2025, Member was seen at [emergency department] for a possible injury to [R1] head. Member reported to Staff that [R1] was in a physical fight at ICHD Summit Residential on Tuesday, October 21 as well as Wednesday, October 22. During both fights, Member hit [R1] head a total number of three times: once during the first fight outside on the patio, once in [R1] bedroom on [R1] nightstand, and in [R1] bedroom again on the floor. Today, Member reported the following symptoms: dizziness, headaches, nausea, vomiting, and feeling the need to vomit without being able to. Member was initially seen at [urgent care], but Staff was told to immediately take Member to ED as an MRI could not be performed. Staff was not given an After Visit Summary at [urgent care] after asking; Staff was urged to leave immediately for [hospital]. Member passed the head injury examination at [hospital], so an MRI was not recommended. However, based on [R1] symptoms, Member was diagnosed with Concussion without loss of consciousness. Member was monitored for about an hour, and [R1] was medically cleared after [R1] symptoms did not worsen." 9. In a joint exit interview, the findings were reviewed with E5 and E6 and no additional comments or statements were provided regarding the findings.


summary: Complaint;Compliance (Annual) - 10/20/2025

raw_content: No deficiencies were found during the on-site  investigation of complaint 00147936 conducted on October 20, 2025.


summary: Complaint - 5/15/2025

raw_content: An on-site investigation of complaint 00125038 was conducted on May 15, 2025 and the following deficiency was cited:

rule: R9-10-718.C.6.a. Medication Services C. If a behavioral health residential facility provides assistance in the self-administration of medication, an administrator shall ensure that: 6. Assistance in the self-administration of medication provided to a resident: a. Is in compliance with an order, and

evidence: 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 one discharged resident 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.

findings: 1. A review of R1's electronic medical record revealed a medication order for "BusPIRone..15 mg...PO TID." 2. A review of R1's electronic medication administration record (MAR) revealed R1 did not receive assistance in the self-administration of "BusPIRone..15 mg...PO TID" on February 13 2025. 3. A review of R1's electronic medical record revealed an incident report dated February 14, 2025. The report stated "...Writer was doing evening medication pass, writer had looked over the scheduled medications for the day and had noticed that a 2pm medication had been skipped. Writer was not informed that member had a 2pm medication. Writer informed member that they had a 2pm medication. Member responded 'yes that is correct.' Writer took member's vitals, asked member who they had felt. Member did not require any emergency care..." 4. In an interview, E1 reported BH9011 had implemented a plan for personnel members who provide medication services. E1 reported all personnel members who provide medication services now wear a watch with timers set for medication pass times. 5. In a joint exit interview, E1 and E2 acknowledged assistance in the self-administration of medication provided to R1 was not in compliance with an order.


summary: Complaint - 3/13/2025

rule: 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 premises with the qualifications, experience, skills, and knowledge necessary to: c. Ensure the health and safety of a resident.

evidence: Based on observation, documentation review, record review, and interview, the administrator failed to ensure a personnel member’s skills and knowledge were verified and documented before providing behavioral health services, as outlined in the facility’s policies and procedures, for one of five personnel members sampled. This deficient practice poses a risk that personnel members may not be qualified to work in a behavioral health residential facility.

findings: 1. A review of facility documentation revealed an incident report (dated March 2025). The report stated: “Members were taken to an NA meeting at 3rd and Alvernon in Tucson, AZ, at St. Mark's Church. At approximately 12:55 PM, member [R1] walked away from staff after the meeting had concluded. [R1] did not respond to redirection or staff attempts to get [R1] back with the group. One staff member stayed with other members, while staff [E1] followed [R1] on foot and called the site supervisor at 1:10 PM to report AWOL. Staff [E2] contacted TPD at 1:11 PM to report AWOL. At 1:30 PM, staff called the member’s guardian to notify them of AWOL. Member continued to refuse to return to site and ran away from staff. Staff [E1] lost sight of the member and was advised to return to the site at 2:20 PM.” 2. A review of the facility’s policy and procedure titled “Staff Qualifications” revealed the following statement: “A personnel member’s skills and knowledge will be verified and documented before the personnel member provides behavioral health services.” 3. A review of the staff schedule revealed that E2 was on the schedule two times in February and twelve times in March. 4. A review of E2’s (hired January 2025) personnel record revealed documentation verifying their skills and knowledge was unavailable for review. 5. In an exit interview, the findings were discussed with O1, and no further statements were made.

rule: 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 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 receives: b. Continuous protective oversight;

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a resident admitted with limited ability to function independently to a behavioral health residential facility, licensed to provide services to individuals whose behavioral health issues limit the individuals' ability to function independently, received continuous protective oversight. The deficient practice posed a risk as R1, who was under the age of 18, did not receive continuous protective oversight while admitted to the facility.

findings: 1. A review of facility documentation revealed an incident report (dated March 2025). The report stated: "Members were taken to an NA meeting... At approximately 12:55 PM, member [R1] walked away from staff after the meeting had concluded. [R1] did not respond to redirection or staff attempts to re-engage. One staff member stayed with the other members, while staff [E1] followed [R1] on foot and called the site supervisor at 1:10 PM to report AWOL. Staff [E2] contacted TPD at 1:11 PM to report AWOL. At 1:30 PM, staff called the member’s guardian to notify them of the AWOL situation. Member continued to refuse to return and ran away from staff. Staff [E1] lost sight of the member and was advised to return to the site at 2:20 PM. Police report number: ..." 2. In an interview, O1 reported that continuous protective oversight was provided until R1 was out of sight. O1 also stated that E2 remained with the other residents to maintain continuous oversight. 3. In an exit interview, the findings were discussed with O1, and no further statements were made.

rule: R9-10-716.A.7.a. Behavioral Health Services 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 or treatment that may present a threat to the resident's health or safety based on the resident's documented diagnosis, treatment needs, developmental levels, social skills, verbal skills, or personal history; or

evidence: Based on documentation review and interview an administrator failed to ensure a resident does not use or have access to any materials, furnishings, or equipment or participate in any activity or treatment which may present a threat to the resident's health or safety based on the resident's documented diagnosis, treatment needs, developmental levels, social skills, verbal skills, or personal history.

findings: 1. A review of facility documentation revealed an incident report. The incident reported was dated February 2025. The document stated " [R2] had utilized [R2] aerosol axe body spray to obtain a high during the night. Member reported that [R2] obtained from [R2’s] hygiene bucket while staff was attempting to inventory it into [R2’s] belongings. Member took as contraband and is not allowed to have body spray on site. Member returned it to overnight staff and reported that it was empty. Bottle was empty after staff received it. It was reported by the night staff that she had been directed by on-call supervisor to monitor member through the night as [R2] was not showing any dangerous signs or indicating the need for medical care. It was agreed that member would continue to be monitored by staff, at 8:30am, this writer was approached by member reporting breathing problems and needing to go to the CRC. Staff reached out to residential nurse, [E3], at 9am and notified unit supervisor, [E4], at 8am. It was directed that member be taken to TMC for medical care and clearance. TMC completed an EKG, blood and urine test. Member tested negative for any illicit substances. TMC staff reported that [R2's] lungs and heart were in good condition and could return to site. Member returned to site at 3pm after being medically cleared. Coworker, [E5],notified guardian and left a message with [R2's] DCS caseworker [E6]." 2. A review of R2’s resident record revealed an initial "Integrated Service Plan." The "Integrated Service Plan" revealed a history of substance abuse and self-harm. 3. In an exit interview, the findings were discussed with O1, and no further statements or documentation were provided.

evidence: Based on documentation review and interview an administrator failed to ensure that poisonous or toxic materials stored by the behavioral health residential facility are maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and are inaccessible to residents.


summary: Complaint - 2/6/2025

raw_content: An on-site investigation of complaints AZ00223141 and AZ00223136 was conducted on February 6, 2025 and the following deficiency was cited :

rule: 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 or treatment that may present a threat to the resident's health or safety based on the resident's documented diagnosis, treatment needs, developmental levels, social skills, verbal skills, or personal history; or

evidence: Based on record review, documentation review, and interview, the administrator failed to ensure a residents did not have access to any materials to present a threat to the resident's health or safety based on the documented diagnosis for R1 and treatment needs for R1 and R2. The deficient practice posed a risk as residents had access to hand sanitizer while admitted into a behavioral health residential facility in contradiction with their behavioral health issue.

findings: 1. A review of R1's (admitted in 2024) medical record revealed a behavioral health assessment (dated in November 2024). The assessment stated " ...Assessment/Diagnosis...F10.10 Alcohol abuse, uncomplicated...F11.90 Opioid use, unspecified, uncomplicated...F12.99 Cannabis use w/ cannabis-induced disorder...F39 Unspecified mood [affective] disorder..." 2. A review of documentation revealed an incident report (dated in February 2025). The incident report stated "...During lunch staff questioned member about what was in [R1's] water bottle...Member became emotional and reported to this writer that [R1] had hand sanitizer in the water bottle...member reported that [R1] got it from the porta potty from the park. Member reported [R1] drank the whole bottle and later recanted that statement and stated that [R1] took the bottle yesterday from the park..." 3. A review of R2's (admitted in 2025) medical record revealed a behavioral health assessment (dated in January 2025). The assessment stated "...F12.10 Cannabis abuse, uncomplicated...F41.1 Generalized Anxiety Disorder...F41.9 Anxiety disorder, unspecified...F43.90 Adjustment disorder, unspecified...F90.2 Attention-deficit hyperactivity disorder...G47.00 Insomnia, unspecified..." 4. A review of documentation revealed an incident report (dated in February 2025). The incident report stated "...Staff observed member slurring [R2's] words, stumbling, and smelled of alcohol...Member admitted to staff that [R2] and another member were drinking hand sanitizer that they took from a park bathroom during an outing the day before. Member admitted to staff that [R2] and another member drank a small portion of the sanitizer the day before...Member admitted that [R2] drank more, informing staff that [R2] used [R2's] water bottle, put about 1.5 inches high with sanitizer and the rest with water. Member stated that [R2] and the other member finished the rest of the hand sanitizer bottle..." 5. In an interview, E1 reported residents are searched upon returning from outings. However, E1 reported the water bottle was not found and it was unclear where R1 may have hid the water bottle. E1 reported it may have been in R1's underwear or waistband. 6. In a joint exit interview, E1, E2, and E3 acknowledged residents had access to materials to present a threat to the resident's health or safety based on the resident's documented diagnosis and treatment needs. This Rule was cite on January 27, 2025. A letter sent to the licensee, on February 12, 2025, stated "...the Department requires that you make immediate corrections of violations that present a threat to the health or safety of a client, resident, patient or agency personnel and still requires that you make corrections to all violations noted in the SOD."


summary: Complaint - 1/27/2025

raw_content: An on-site investigation of complaint AZ00221829 was conducted on January 27, 2025 and the following deficiency was cited:

evidence: Based on observation, record review, and interview, the administrator failed to ensure a resident did not have access to any materials to present a threat to the resident's health or safety based on the resident's documented personal history. The deficient practice posed a risk as R1 had access to metal wire after a possible self-harming incident.

findings: 1. The Compliance Officer observed located in a bin in R1's bedroom the following: a metal wire which contained sharp edges. 2. A review of R1's (admitted in 2024) medical record revealed a behavioral health assessment (dated in November 2024). The assessment stated " ...Assessment/Diagnosis...F10.10 Alcohol abuse, uncomplicated...F11.90 Opioid use, unspecified, uncomplicated...F12.99 Cannabis use w/ cannabis-induced disorder...F39 Unspecified mood [affective] disorder..." 3. A review of R1's electronic medical record revealed an individual counseling session note (dated in January 2025). The counseling note stated "...member indicated it was because [R1] was 'tattooing' [R1's] hand. Member did not see carving [R1's] hand with an earring as self-harming other than just tattooing...denied any intent to hurt [R1's] self or SI..." 4. In an interview, E1 reported R1 had a visit with R1's sister the day prior and R1's sister had a new tattoo by "stick and poke" and R1 expressed wanting to be like R1's sister. 5. In a joint exit interview, E1 and E2 acknowledged R1 had access to a sharp metal wire.


summary: Complaint - 12/5/2024

raw_content: An on-site investigation of complaint AZ00219404 was conducted on December 5, 2024, and no deficiencies were cited.


summary: Complaint;Compliance (Annual) - 9/19/2024

raw_content: The following deficiencies were found during the on-site compliance inspection and investigation of complaints AZ00215629 and AZ00216227 conducted on September 19, 2024:

rule: C. An administrator shall ensure that: 1. Policies and procedures are established, documented, and implemented to protect the health and safety of a resident that: e. Cover cardiopulmonary resuscitation training including: i. The method and content of cardiopulmonary resuscitation training, which includes a demonstration of the individual's ability to perform cardiopulmonary resuscitation; ii. The qualifications for an individual to provide cardiopulmonary resuscitation training; iii. The time-frame for renewal of cardiopulmonary resuscitation training; and iv. The documentation that verifies that the individual has received cardiopulmonary resuscitation training;

evidence: Based on documentation review, record review, and interview, the administrator failed to implement policies and procedures to protect the health and safety of a resident to cover cardiopulmonary resuscitation (CPR) training to include the time-frame for renewal of CPR training. The deficient practice posed a risk if E10 was unable to meet a resident's needs during an emergency, accident, or injury; and the standards expected of employees were not followed.

findings: 1. A review of the facility's policies and procedures revealed a policy titled "Staff Qualifications" (dated in December 2023). The policy stated "...Staff providing in-person direct care services are required to show evidence of a valid, in-person CPR and First Aid certification upon hire and are required to continuously maintain certification throughout term of employment..." 2. A review of E10's (hired as a behavioral health technician) personnel record revealed documentation of CPR training issued August 8, 2022 and valid until August 2024. However, documentation of current CPR training as required by policies and procedures was not available for review. 3. A review of the facility's daily staffing schedules revealed E10 did not work alone. 4. In an interview, E2 reported E10 had not worked alone. 5. In a joint interview, E2, E3 and E6 acknowledged E10's CPR training was not renewed to continuously maintain certification and the policy and procedure was not implemented.

rule: G. An administrator shall provide written notification to the Department of a resident's: 2. Self-injury, within two working days after the resident inflicts a self-injury or has an accident that requires immediate intervention by an emergency medical services provider.

evidence: Based on documentation 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 requiring immediate intervention by an emergency medical services provider. The deficient practice posed a risk as the Department was unable to determine if there was an immediate health and safety risk to residents admitted into the facility.

findings: 1. A review of facility documentation revealed a document titled "Incident, Accident, Death Report Form" (dated in September 2024). The document stated "...Member became distressed in the evening after guardian did not show for in person visit AEB punching [R4's] wall, crying in [R4's] room, yelling [expletive] this, [expletive] you, I am going to smoke a bubble, put that down in my note." Member punched [R4's] wall multiple times in [R4's] room. Staff then observed that member's knuckles on both hands were swollen and tender/ very painful...instructed writer to transport member to urgent care to be evaluated...doctor reported member had a 'healing fracture' on [R4's] [extremity] but reported that the injury did not happen today...no c urgent fractures or breaks from incident tonight and stated member most likely had sprained [R4's] hands. No further medical treatment was deemed required...Member guardian was attempted to be contacted via telephone and did not answer. Behavioral health team was notified via email...NOTIFICATIONS...Case Management/Assigned CSP/Provider Parent / Guardian / TSS Case Worker..." However, documentation to demonstrate BH9011 provided written notification to the Department within two working days of a resident's self-injury requiring immediate intervention by an emergency medical services provider was not available for review. 2. A review of Department documentation revealed documentation to demonstrate BH9011 provided written notification to the Department of R4's self-injury was not available for review. 3. In a joint interview, E2, E3 and E6 acknowledged written notification to the Department of R4's self-injuries was not provided to the Department.

rule: G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes: 3. Documentation of: c. The individual's completed orientation and in-service education as required by policies and procedures;

evidence: 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, for one of eleven personnel members. The deficient practice posed a risk if a personnel member was not qualified to work in a health care institution.

findings: R9-10-101.155. "Orientation" means the initial instruction and information provided to an individual before the individual starts work or volunteer services in a health care institution. 1. A review of E10's personnel record revealed documentation of completed orientation was not available for review. 2. In a joint interview, E2, E3, and E6 acknowledged documentation of E10's completed orientation was not available for review.

rule: A. An administrator shall ensure that: 3. Except as provided in subsection (A)(4), general consent is obtained from: a. An adult resident or the resident's representative before or at the time of admission, or b. A resident's representative, if the resident is not an adult;

evidence: Based on record review and interview, the administrator failed to ensure general consent was obtained from a child resident before or at the time of admission, for one of two current residents sampled and for one of three discharged residents sampled. The deficient practice posed a risk as residents received treatment without consent.

findings: R9-10-101.98."General consent" means documentation of an agreement from an individual or the individual's representative to receive ... behavioral health services to address the individual's behavioral health issues. 1. A review of R1's medical record (admitted in 2024) revealed documentation of general consent. However, the document was not signed. 2. A review of R3's medical record (discharged in 2024) revealed documentation of general consent was not available for review. 3. In a joint interview, E2, E3 and E6 acknowledged general consent was not obtained from R1 and R3 before or at the time of admission.

rule: A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that: 4. Includes: c. The signature of the resident or the resident's representative, and date signed, or documentation of the refusal to sign;

evidence: Based on record review and interview, the administrator failed to ensure a treatment plan was developed for each resident to include the signature of the resident's representative, and the date signed, or documentation of the refusal to sign, for one of two current residents sampled and for one of three discharged residents sampled. The deficient practice posed a risk if the treatment plan was not developed to articulate decisions and agreements.

findings: 1. A review of R1's medical record revealed a treatment plan (dated in July 2024). However, the treatment plan did not include the signature of the resident's representative, and the date signed, or documentation of the refusal to sign. 2. A review of R3's medical record revealed a treatment plan (dated in July 2024). However, the treatment plan did not include the signature of the resident's representative, and the date signed, or documentation of the refusal to sign. 3. In a joint interview, E2, E3 and E6 acknowledged R1's and R3's treatment plans did not include the signature of the resident's representative, and date signed, or documentation of the refusal to sign.

rule: A. An administrator shall ensure that: 2. At the time of admission, a resident or the resident's representative receives a written copy of the requirements in subsection (B) and the resident rights in subsection (E); and

evidence: Based on record review and interview, the administrator failed to ensure at the time of admission, a resident or the resident's representative received a written copy of the requirements in subsection (B) and the resident rights in subsection (E), for two of two current residents sampled and for three of three discharged residents sampled.

findings: 1. A review of R1's medical record revealed a document titled "Notice Of Patient Right & Responsibilities" (dated in July 2024). However, the document did not meet the requirements in subsection (B) and the resident rights in subsection (E). 2. A review of R2's medical record revealed a document titled "Notice Of Patient Right & Responsibilities" (dated in September 2024). However, the document did not meet the requirements in subsection (B) and the resident rights in subsection (E). 3. A review of R3's medical record revealed a document titled "Notice Of Patient Right & Responsibilities" (dated in July 2024). However, the document did not meet the requirements in subsection (B) and the resident rights in subsection (E). 4. A review of R4's medical record revealed a document titled "Notice Of Patient Right & Responsibilities" (dated in June 2024). However, the document did not meet the requirements in subsection (B) and the resident rights in subsection (E). 5. A review of R5's medical record revealed a document titled "Notice Of Patient Right & Responsibilities" (dated in June 2024). However, the document did not meet the requirements in subsection (B) and the resident rights in subsection (E). 6. In a joint interview, E2, E3 and E6 acknowledged R1, R2, R3, R4, and R5 did not receive a written copy of the requirements in subsection (B) and the resident rights in subsection (E).

rule: A. An administrator shall ensure that: 2. If a behavioral health residential facility is 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 receives: b. Continuous protective oversight;

evidence: Based on documentation review and interview, the administrator failed to ensure a resident admitted with limited ability to function independently to a behavioral health residential facility, licensed to provide behavioral health services to individuals whose behavioral health issue limits the individuals' ability to function independently, received continuous protective oversight. The deficient practice posed a risk as two (2) minors did not receive continuous protective oversight while admitted to a behavioral health residential facility.

findings: 1. A review of facility documentation revealed a document titled "Incident, Accident, Or Death Report" (dated in September 2024). The document stated "...At about 19:40 Staff 1 was told by peer that member just opened the bathroom door and let [R4] peer into the bathroom. Staff 1 knocked on bathroom door cued member it was time to exit bathroom member replied 'I'm almost done.' Staff 1 stated it was time to get out now. Staff 1 asked Staff 2 to assist with checking TV room and lunchroom to see if peer was accounted for Staff 2 replied [R4] was not and replaced Staff 1 standing by bathroom door cueing member it was time to exit while Staff 1 did a complete sweep of hallway checking each h room. Peer was not accounted for, and member still had not exited bathroom. Staff 2 contacted On Call to gain permission to access [gender] restroom after explaining what occurred. On Call approved entry. Staff 1 knocked on door and stated to the member that they were entering the bathroom. Member stated 'I'm almost done.' Staff 1 entered as cued and observed [gender] and [gender] clothing on bathroom floor, curtain drawn closed and what appeared to be two members in the shower on the floor while water was running and what appeared to be [R4] on top of [R3]. Staff 1 cued member and peer to turn off the water and exit the shower. Member refused and required multiple cues. Member stated 'you're not allowed to come into the bathroom and see us naked.' Staff 1 asked member to exit shower and if [R3] would like the white towel that was visible on the bathroom floor...Member exited the shower with white towel...peer stayed behind shower curtain while Staff 2 got a towel for peer. Member continuously requested bathroom door to be shut with peer still inside stating 'I'm not getting dressed in front of you, you're not allowed to see me naked.' Peer exits the shower with towel...and walks [sic] towards member. Member and peer proceed to laugh and kiss..." 2. In an interview, E2 reported R4 went into the restroom at 7:37 PM, E1 was notified at 7:41 PM, and a personnel member entered the restroom at 7:43 PM. E2 reported R4 asked staff for a snack. While staff was collecting the snack, R4 left the scene. After conducting a sweep throughout the facility, staff was notified R3 had opened the rest room door and R4 entered the rest room. E2 reported staff attempted to get R3 and R4 to exit the restroom then notified E1 to gain access into the rest room. E2 reported staff entered the rest room and eventually separated R3 and R4. 3. In a joint interview, E2, E3 and E6 acknowledged the residents, who were under the age of 18, did not receive continuous protective oversight.


summary: Complaint - 8/20/2024

raw_content: An on-site investigation of complaint AZ00213887 was conducted on August 20, 2024 and the following deficiency was cited :

rule: A.R.S. § 36-406.1.c. Powers and duties of the department In addition to its other powers and duties: 1. The department shall: c. Have access to books, records, accounts and any other information of any health care institution reasonably necessary for the purposes of this chapter.

evidence: Based on documentation review and interview, the department did not have access to books, records, accounts and any other information of any health care institution reasonably necessary for the purposes of this chapter. The deficient practice posed a risk as the facility established and implemented a policy that restricted how the Department collects evidence needed to determine substantial compliance.

findings: 1. In an interview, E1 reported E1 was directed to inform the Compliance Officer that photos of facility documentation, medical records, and personnel records were not allowed. However, BH9011 would provide the Compliance Officer with copies of any documentation the Compliance Officer requested. 2. In a joint interview, E1 and E2 acknowledged the department shall have access to books, records, accounts and any other information of any health care institution reasonably necessary for the purposes of this chapter and E1 was directed to not allow the Compliance Officer to take photos as evidence.


summary: Initial Monitoring - 4/23/2024

raw_content: No deficiencies were found during the on-site abbreviated follow-up inspection conducted on April 23, 2024.


summary: Compliance (Initial) - 11/1/2023 - 11/29/2023

raw_content: No deficiencies were found during the on-site initial inspection conducted on November 1, 2023 and the off-site documentation review completed on November 29, 2023.


facility_name: NEW HOPE OF ARIZONA, INC

summary: Compliance (Annual) - 1/9/2026

raw_content: No deficiencies were found during the on-site compliance inspection conducted on January 9, 2026.


summary: Compliance (Annual) - 12/30/2024

raw_content: The following deficiency was found during the on-site compliance inspection conducted on December 30, 2024:

evidence: 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.

findings: 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.


summary: Initial Monitoring - 4/23/2024