summary: Compliance (Annual) - 4/27/2023

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on April 27, 2023:

inspection_type: Compliance (Annual)

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 develop and administer a training program for all staff regarding fall prevention and fall recovery to include initial training and continued competency training in fall prevention and fall recovery. The deficient practice posed a risk if employees were not properly trained to assist a resident in an emergency, the Department was unable to determine substantial compliance as the required documentation was not available during the inspection, and was not provided to the Department within two hours after a Department request.

findings: 1. A review of the facility's policies and procedures revealed a policy titled "Staff Training" dated March 15, 2022. The policy stated: "Direct care staff will receive initial orientation and ongoing inservice training based on state regulations and the needs of the residents being served in the community..." However, evidence of a fall prevention and fall recovery training program was not available for review. 2. A review of E2's personnel record revealed documentation of initial training or continued competency training in fall prevention and fall recovery was not available for review. 3. A review of E3's personnel record revealed documentation of initial training or continued competency training in fall prevention and fall recovery was not available for review. 4. A review of E4's personnel record revealed documentation of initial training or continued competency training in fall prevention and fall recovery was not available for review. 5. In an interview, E1 acknowledged the facility had not developed and administered a training program for all staff regarding fall prevention and fall recovery.

evidence: Based on record review, documentation review, and interview, the administrator failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance.

findings: 1. A review of E4's personnel record revealed documentation of current contracted services including a description of the contracted services provided was not available for review. 2. A review of E4's personnel record revealed documentation to demonstrate E4's skills and knowledge were verified and documented was not available for review. 3. A review of E4's personnel record revealed documentation of E4's completed orientation was not available for review. 4. A review of E3's personnel record revealed documentation of compliance with A.R.S. \'a7 36-411(C)(1)-(2) was not available for review. 5. A review of E4's personnel record revealed documentation of compliance with A.R.S. \'a7 36-411(C)(1)-(2) was not available for review. 6. A review of the facility documentation revealed daily staffing schedules were not available for review. 7. A review of R1's medical record revealed documentation of general consent obtained in subsection (A)(3) was not available for review. 8. A review of R2's medical record revealed documentation of general consent obtained in subsection (A)(3) was not available for review. 9. A review of R1's medical record revealed documentation indicating R1 provided evidence of freedom from infectious TB before or within seven calendar days after R1's admission date was not available for review. Based on R1's admission date, documentation of evidence of freedom from infectious TB was required. 10. A review of R2's medical record revealed documentation indicating R2 provided evidence of freedom from infectious TB before or within seven calendar days after R2's admission date was not available for review. Based on R2's admission date, documentation of evidence of freedom from infectious TB was required. 11. A review of R1's medical record revealed a treatment plan per R9-10-708(A)(4) was not available for review. 12. A review of R2's medical record revealed a treatment plan per R9-10-708(A)(4) was not available for review. 13. The Compliance Officer requested to review counseling notes for the month of April 2023 for R1, however, counseling notes for R1 were available for review. 14. The Compliance Officer requested to review the facility's pest control program including a pest control contract, however, documentation of a pest control program for BH7288 was not available for review. 15. A review of E2's personnel record revealed documentation of initial training or continued competency training in fall prevention and fall recovery was not available for review. 16. A review of E3's personnel record revealed documentation of initial training or continued competency training in fall prevention and fall recovery was not available for review. 17. A review of E4's personnel record revealed documentation of initial training or continued competency training in fall prevention and fall recovery was not available for review. 18. In an interview, E1 acknowledged documentation required by Article 7 was not provided to the Department within two hours after a Department request.

evidence: Based on record review and interview, the administrator failed to ensure documentation of current contracted services, including a description of the contracted services provided, was maintained. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not available during the inspection, and the documentation was not provided at the exit interview.

findings: 1. A review of E4's personnel record revealed documentation of current contracted services, including a description of the contracted services provided, was not available for review. 2. In an interview, E1 acknowledged E4's documentation of current contracted services, including a description of the contracted services to be provided, was not maintained.

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: a. The individual's qualifications, including skills and knowledge applicable to the individual's job duties;

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel members to include documentation of the individual's skills and knowledge, for one behavioral health professional (BHP) sampled. The deficient practice posed a risk if a personnel member was unable to meet a resident's needs, the Department was unable to determine substantial compliance as the documentation was not in the personnel record during the inspection, and the documentation was not provided within two hours after a Department request.

findings: 1. A review of the facility's policies and procedures revealed an undated policy titled "Personnel Members Requirements & Verification of Qualifications, Skills and Knowledge". The policy stated: "Verify the skills and knowledge necessary to perform the duties consistent with the personnel member's job description for working in this agency, in addition to the specific skills and knowledge necessary to: a. Protect resident's rights. b. Provide treatment that promotes resident's dignity, independence, individuality, strengths, privacy, and choice. c. Recognize obvious symptoms of a mental disorder, personality disorder, or substance abuse. d. Provide the behavioral health services that the agency is authorized to provide and that the personnel members member is qualified to provide. e. Meet the unique needs of the resident populations served by the agency or the personnel members member, such as adults aged 18 years and older, individuals who have substance abuse problems, individuals who are seriously mentally ill, or individuals who have co-occurring disorders...Provide the activities or behavioral health services identified in the personnel members and member's job description or the agency's policy and procedure." 2. A review of E4's personnel record revealed documentation to demonstrate E4's skills and knowledge were verified and documented was not available for review. 3. In an interview, E1 reported E1 had documentation of E4's skills and knowledge, however, E1 could not locate the documentation. E1 acknowledged documentation to demonstrate E4's skills and knowledge were verified and documented was not provided for review.

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 as required by policies and procedures, for one of three personnel members sampled. The deficient practice posed a risk if E4 was unable to meet the needs of the residents, the Department was unable to determine substantial compliance as the documentation was not in the personnel record during the inspection, and the documentation was not provided within two hours after a Department request.

findings: 1. Arizona Administrative Code (A.A.C.) R9-10-101.155. states "Orientation" means "the initial instruction and information provided to an individual before the individual starts work or volunteer services in a health care institution." 2. A review of the facility's policies and procedures revealed a policy titled "R9-10-706 ORIENTATION" dated March 15, 2022. The policy stated: "Upon hiring, all new hire staff will need to go through our 4-hour training process before working alone. Professional test may be given to ensure that enough pertinent information has been retained. Ongoing staff meetings will take place at least, but not limited to, once every 30 days." 3. A review of E4's personnel record revealed documentation of E4's completed orientation was not available for review. 4. In an interview, E1 reported E4 completed orientation, however, E1 could not locate the documentation. E1 acknowledged documentation of E4's orientation was not available for review.

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: e. The individual's compliance with requirements in A.R.S. §§ 36-411, 36-411.01, and 36-425.03, as applicable;

evidence: Based on record review and interview, the administrator failed to ensure a personnel record included documentation of compliance Arizona Revised Statutes (A.R.S.) \'a7 36-411, for two of three personnel members sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not in the personnel record during the inspection, and the documentation was not provided within two hours after a Department request.

findings: 1. A.R.S. \'a7 36-411(C) states: "Owners shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency. 2. Verify the current status of a person's fingerprint clearance card." 2. A review of E3's personnel record revealed documentation of compliance with A.R.S. \'a7 36-411(C)(1)-(2) was not available for review. 3. A review of E4's personnel record revealed documentation of compliance with A.R.S. \'a7 36-411(C)(1)-(2) was not available for review. 4. In an interview, E1 acknowledged documentation of compliance with A.R.S. \'a7 36-411(C)(1)-(2) for E3 and E4 was not available for review.

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, scheduled work hours, and name of each employee assigned to work, including on-call personnel members, included documentation of the employees who worked each calendar day and the hours worked by each employee, and was maintained for at least 12 months after the last date on the documentation. The deficient practice posed a risk as there was no record to verify sufficient, qualified staff were present or available to meet the needs of the residents, the Department was unable to determine substantial compliance as the documentation was not available during the inspection, and the documentation was not provided within two hours after a Department request.

findings: 1. A review of Department documentation revealed the license for BH7288 was effective on May 9, 2022. 2. A review of the facility documentation revealed daily staffing schedules were not available for review. 3. In an interview, E1 reported the facility maintained two shifts, 7:00 AM to 7:00 PM, and 7:00 PM to 7:00 AM. E1 acknowledged a daily staffing schedule indicating the date, scheduled work hours, and name of each employee assigned to work, including on-call personnel members, was not available for review.

rule: A. An administrator shall ensure that: 5. The general consent obtained in subsection (A)(3) is documented in the resident's medical record;

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure that general consent obtained in subsection (A)(3) is documented in the resident's medical record, for two of two residents sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not in the medical records during the inspection, and the documentation was not provided at the exit interview.

rule: 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 b. As specified in R9-10-113.

evidence: Based on record review and interview, the administrator failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident's admission, for two of two residents sampled. The deficient practice posed a TB exposure risk to residents, the Department was unable to determine substantial compliance as the documentation was not in the medical records during the inspection, and the documentation was not provided within two hours after a Department request.

findings: 1. A review of R1's medical record revealed documentation indicating R1 provided evidence of freedom from infectious TB before or within seven calendar days after R1's admission date was not available for review. Based on R1's admission date, documentation of evidence of freedom from infectious TB was required. 2. A review of R2's medical record revealed documentation indicating R2 provided evidence of freedom from infectious TB before or within seven calendar days after R2's admission date was not available for review. Based on R2's admission date, documentation of evidence of freedom from infectious TB was required. 3. In an interview, E1 reported R1 and R2 had TB tests from previous facilities, however, E1 did not have the documentation. E1 acknowledged documentation indicating R1 and R2 provided evidence of freedom from infectious TB before or within seven calendar days after R1's and R2's admission was not available for review.

rule: C. An administrator shall ensure that a resident's medical record contains: 12. Treatment plans;

evidence: Based on record review and interview, the administrator failed to ensure a resident's medical record contained a treatment plan, for two of two residents sampled. The deficient practice posed a risk as there was no treatment plan to direct services to be provided to a resident, the Department was unable to determine substantial compliance as the required documentation was not in the medical record during the inspection, and was not provided to the Department within two hours after a Department request.

findings: 1. A review of R1's medical record revealed a treatment plan per Arizona Administrative Code (A.A.C.) R9-10-708(A)(4) was not available for review. 2. A review of R2's medical record revealed a treatment plan per A.A.C. R9-10-708(A)(4) was not available for review. 3. In an interview, E1 reported treatment plans are done verbally over the phone to plan treatment. E1 acknowledged a treatment plan for R1 and R2 was not available for review.

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

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure counseling was offered as described in the behavioral health residential facility's scope of services. The deficient practice posed a risk if a resident did not receive treatment at the behavioral health residential facility to cure, improve, or palliate their behavioral health issue, the Department was unable to determine substantial compliance as the documentation was not available in the medical records during the inspection, and the licensee did not provide the documentation within two hours after a Department request.

findings: 1. A review of the facility's policies and procedures revealed an undated policy titled "Scope of Services". The policy stated: "Type of counseling Individual # Of Contacts Minimum 1 hr. sessions per week-per resident...Group # Of Contacts Minimum 1 hr. sessions per week-per resident..." 2. The Compliance Officer requested to review counseling notes for the month of April 2023 for R1, however, counseling notes for R1 were available for review. 3. In an interview, E2 reported R1 would be starting counseling the following week. E2 acknowledged counseling was not offered as described in the behavioral health residential facility's scope of services.

rule: C. An administrator shall: 3. Maintain documentation of a current fire inspection.

evidence: Based on observation and interview, the administrator failed to ensure the facility maintained documentation of a current fire inspection.

findings: 1. During the environmental inspection of the facility, the Compliance Officer observed a fire inspection report dated November 4, 2021 from the City of Phoenix posted on the wall in a hallway of the facility. The expiration date of the inspection report was November 4, 2022. 2. In an interview, E1 acknowledged the fire inspection for the facility was not current.

rule: A. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 1. The premises and equipment are: c. Free from a condition or situation that may cause a resident or other individual to suffer physical injury;

evidence: Based on observation and interview, the administrator failed to ensure the premises was free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a risk as a ligature point was identified.

findings: 1. During the environmental inspection of the facility, the Compliance Officer observed one grab bar attached to the wall next to the shower, and one grab bar attached to the wall by the toilet area, in a hallway bathroom accessible to residents. 2. In an interview, E1 acknowledged the grab bars posed a potential ligature hazard, and the premises was not free from a condition or situation that may cause a resident or other individual to suffer physical injury.

rule: A. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 2. A pest control program that complies with A.A.C. R3-8-20l(C)(4) is implemented and documented;

evidence: Based on documentation review and interview, the manager failed to ensure a pest control program in compliance with Arizona Administrative Code (A.A.C.) R3-8-201(C)(4) was documented. The deficient practice posed a risk as the facility standards were not documented, the Department was unable to determine substantial compliance as the documentation was not available during the inspection, the documentation was not provided within two hours after a Department request.

findings: 1. The Compliance Officer requested to review the facility's pest control program including a pest control contract, however, documentation of a pest control program for BH7288 was not available for review. 2. In an interview, E1 reported the facility has a current pest control contract, however, E1 could not open the documentation on the computer. E1 acknowledged a pest control program compliant with A.A.C. R3-8-20l(C)(4) was not documented.


state: AZ

facility_name: INTERMOUNTAIN CENTERS FOR HUMAN DEVELOPMENT, INC

summary: Complaint - 2/10/2026

raw_content: No deficiencies were found during the on-site  investigation of complaint 00158566 conducted on February 10, 2026.

inspection_type: Complaint


summary: Complaint - 12/16/2025

raw_content: No deficiencies were found during the on-site  investigation of complaint 00153291 conducted on December 16, 2025.


summary: Complaint - 11/5/2025

raw_content: The following deficiencies were found during the on-site investigation of complaint 00148989 conducted on November 5, 2025.

rule: R9-10-703.C.2.a. Administration C. An administrator shall ensure that: 2. Policies and procedures for behavioral health services and physical health services are established, documented, and implemented to protect the health and safety of a resident that: a. Cover resident screening, admission, assessment, treatment plan, transport, transfer, discharge planning, and discharge;

evidence: Based on record review, documentation review, and interview, the administrator failed to ensure a policies and procedures were implemented to protect the health and safety of a resident which covered resident treatment plans. The deficient practice posed a risk as established and documented policies and procedures were not implemented.

findings: 1. A review of facility documentation revealed a document titled "INCIDENT, ACCIDENT OR DEATH REPORT," (IAD) dated on October 27, 2025. The IAD stated, "Date of Incident: [October 2025]... DESCRIPTION OF THE INCIDENT... On [October 2025], at approximately 8:28 PM, on the Desert River Unit, the member was cued by AAN staff to transition from self-administering [R1's] medication to [R1's] bedroom for solo leisure and sleep. The member resisted verbal cues from multiple staff, refusing to transition as directed. At approximately 8:50 PM, after eventually entering [R1's] room, the member began punching [R1's] bedroom walls repeatedly. Shortly afterward, the member exited [R1's] room and entered the third bathroom, where [R1] struck the wall several times, causing a hole in the wall. At 9:02 PM, the on-call supervisor was contacted and informed of the member's aggressive behavior towards property. Staff continued to monitor the member and implement safety care verbal de-escalation interventions, while AAN utilized the recommendations outlined in the member's crisis plan to support emotional regulation and minimize escalation. Between 9:05 PM and 9:28 PM, the member was observed pacing the unit and intermittently returning to [R1's] room, continuing to punch the walls. The member briefly relaxed in [R1's] room at 9:28 PM, but soon re-engaged in aggression again striking the walls and pacing. At approximately 9:40 PM, the member attempted to open the outdoor courtyard door, pushing and kicking the door handle. AAN staff provided continued verbal redirection, calm tone, and grounding support, prompting the member to transition back to [R1's] room. The member punched the walls several additional times before requesting to go back outside to the basketball area with AAN. At approximately 9:50 PM, the member transitioned outdoors with AAN to the basketball courtyard for coping skill practice and de-escalation. Between 9:50 PM and 10:54 PM, the member engaged in verbal processing, venting, and emotional regulation exercises with AAN. [R1] expressed feeling overwhelmed and disclosed thoughts of wanting to punch a peer, but was able to talk through [R1's] emotions and discuss peer-related social dynamics appropriately. During this time, AAN observed swelling and bruising to the member's right hand, which the member stated occurred from punching walls. The member also reported pain on the bottom of [R1's] left foot, though [R1] remained able to walk independently. After discussion and cooling down, the member reported feeling tired and agreed to contract for safety. [R1] drank water, used the restroom, and was given an ice pack for [R1's] right hand. The member fell asleep at approximately 11:24 PM. At 11:05 PM, the on-call supervisor was updated on the member's transition to bed and her physical symptoms. At 11:26 PM, AAN contacted the on-call nurse regarding the member's hand swelling and foot pain. The nurse advised that the member could wait until the following day for a medical evaluation. A final update was provided to on-call at 11:31 PM. On 10/27/2025 at 7:05 AM, AAN contacted the DCS guardian for a 14-minute phone discussion regarding the member's behaviors, physical symptoms, and follow-up plan. The guardian was informed of interventions, medical recommendations, and the member's improved presentation. At 7:24 AM, AAN left a voicemail for the Residential Nurse reporting the member's hand and foot symptoms and requesting a follow-up assessment. At 8:14 AM, the Residential Nurse conducted an in-person assessment of the member, noting swelling and bruising to the right hand and tenderness on the left foot. The nurse determined that Urgent Care or ER services were not needed and recommended that a PCP appointment be scheduled for further evaluation. The member was calm, cooperative, and physi [sic]... MEDICAL SERVICES RECEIVED: On-call nurse contacted regarding swelling and pain to right hand and left foot. Ice pack provided for right hand [sic]. Nurse advised no urgent care or emergency services needed at that time. Residential Nurse was initially contacted via voicemail at 7:24 AM on 10/27/2025 regarding the member's symptoms and need for assessment. Residential Nurse assessed member [sic] the following morning at 8:14 AM on 10/27/2025. Residential Nurse recommended scheduling a PCP appointment for followup [sic] evaluation. Member [sic] monitored for physical and emotional stability... ACTIONS TAKEN AND/OR RECOMMENDED... Debrief with counseling with member/family, Debrief among staff and/or supervisors, Crisis Planning, CFT/ART, Update ISP and or Assessment..." 2. A review of R1's medical record revealed an incident report describing an event which occurred in October 2025, and was submitted by E7 more than 48 hours after an emergency safety response was used for a resident. The incident report stated, "Submitted [October 2025] at 07:43 PM by [E7]... Date of Incident: [October 2025]... Time: 02:56 PM... Site Location: ICHD Desert River... Incident Location... The classroom within the Desert River Facility... Incident Member Abuse/Mistreatment... Member Abuse/Mistreatment: Peer to Peer Physical Aggression that results in injury (bruises, cuts, etc.) Do not choose if member needed EMS called or go to ER. (Residential Sites only)... Was Member Placed in a Physical Hold by Staff During Incident?: Yes... Incident Description... Member was engaging in verbal aggression around 1440 towards a peer, making comments including "I've been waiting for his since you got here" and "Why you hiding behind your friend? Come on, let's go". TPD was called at 2:40pm to initially report the verbal threats. Peer did not respond to any of the threats and continued to focus on [R1's] classwork. Member ceased with verbal threats so Staff called TPD to cancel the unit. Shorty after, around 1450 the Member got up from [R1's] seat and rushed towards [R1's] peer and physically assaulted peer by throwing a barrage of punches to peer's torso and head. Staff 2 and Staff 3 interfered and put Member in a physical hold to prevent Member from landing further punches. Staff 4 positioned [Staff 4] between Member and peer. Staff 1 and Staff 3 removed all other peers from the classroom. Staff 1 called TPD again at 1453 and notified Staff 1 that they would be enroute. Staff 1 contacted DCS guardian at 1504 but they did not answer so a voicemail was left. Member's probation officer was called at 1506 but also did not answer so a voicemail was left... Member Condition Before Incident: Member was alert and stirred up... Member Condition After Incident: Agitated... Medical Services Provided to Member Related to Incident: Member was assessed by residential RN, [E5], and was medically cleared... Medical Services Action: Guardian Contacted... Actions Taken and/or Recommended: Debrief with counseling with member/family, Debrief among staff and/or supervisors... Document Routing... Status: Pending... Approvers: [E5] RN, BHP-Staff (Pending)... [E11] BHT-Staff (Accepted)... [E9] BHPP-Staff (Accepted)... [E1] BHPP-Staff (Pending)..." 3. A review of R1's medical record revealed an initial (dated in September 2025) and updated crisis plan (dated in October 2025). The updated crisis plan stated, "Recommended plan of action... [R1] will be separated from the other individual(s). Member shared that [R1] understanding when [R1] has to be separated from others for [R1's] and other's [sic] safety. Staff will keep member in line of sight while in program. Staff will become familiarized with the crisis plan for the purpose of being proactive in the event of de-escalating aggressive behaviors.. In the event of perceived or observed escalation, additional staff assistance will be requested by staff on the floor. Staff will follow protocol of notification to supervisor, on-call(after hours) [sic] and guardian in the event of a major behavior such as physical aggression..." However, there was no evidence of an updated treatment plan. 4. A review of facility documentation revealed staffing schedules dated for October 2025 and November 2025. The October 2025 schedule listed E11 was scheduled to work on November 1, 2025 as the "...1-1 w/[R1]..." The November 2025 schedule listed E11 was scheduled to work on November 2, 2025 and November 3, 2025 as the "...1-1 w/[R1]..." and two other staff members were scheduled as the "...1-1 w/[R1]..." on November 4, 2025. 5. In an interview, E1 reported the facility did not review and update R1's treatment plan after either reported incidents; however, R1's crisis plan was updated. 6. A review of facility documentation revealed a policy titled "Assessment and Treatment Planning" (dated on August 11, 2025). The procedure stated, "Intermountain Centers for Human Development and its Affiliate Organizations staff shall review and update the treatment plan according to the review date specified in the initial or interim treatment plan, at least annually, when a treatment goal is accomplished or changed, and when additional information is identified that affects the member’s assessment... The development of a crisis/safety plan shall be completed in alignment with the member’s service and treatment plan, and any existing behavior plan if applicable..." 7. In an exit interview, the findings were reviewed with E1, E2, and E3, and no further documentation or comments were provided.

rule: R9-10-703.C.2.d. Administration C. An administrator shall ensure that: 2. Policies and procedures for behavioral health services and physical health services are established, documented, and implemented to protect the health and safety of a resident that: d. Cover emergency safety responses;

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure policies and procedures for behavioral health services and physical health services were implemented to protect the health and safety of a resident which covered emergency safety responses. The deficient practice posed a risk as the established and documented policies and procedures were not followed, and the repeated violation shows a pattern on non-compliance to ensure the health and safety of residents.

findings: 1. A review of facility documentation revealed a policy titled "Permissible Behavior Management Techniques" (dated on July 28, 2025). The procedure stated, "Reporting... Within 24 hours after an emergency safety response is used for a member, the following information is entered into the member's medical record and reviewed with the staff's administrator or clinical director... The date and time the emergency safety response was used... The name of each staff member who used an emergency safety response... The specific emergency safety response used... The staff member or resident behavior, event, or environmental factor that caused the need for an emergency safety response... Any injury that resulted from the emergency safety response..." 2. A review of R1's medical record revealed an incident report describing an event which occurred in October 2025, and submitted by E7 more than 48 hours after an emergency safety response was used for a resident. The incident report stated, "Submitted [October 2025] at 07:43 PM by [E7]... Date of Incident: [October 2025]... Time: 02:56 PM... Site Location: ICHD Desert River... Incident Location... The classroom within the Desert River Facility... Incident Member Abuse/Mistreatment... Member Abuse/Mistreatment: Peer to Peer Physical Aggression that results in injury (bruises, cuts, etc.) Do not choose if member needed EMS called or go to ER. (Residential Sites only)... Was Member Placed in a Physical Hold by Staff During Incident?: Yes... Incident Description... Member was engaging in verbal aggression around 1440 towards a peer, making comments including "I've been waiting for this since you got here" and "Why you hiding behind your friend? Come on, let's go". TPD was called at 2:40pm to initially report the verbal threats. Peer did not respond to any of the threats and continued to focus on [R1's] classwork. Member ceased with verbal threats so Staff called TPD to cancel the unit. Shorty after, around 1450 the Member got up from [R1's] seat and rushed towards [R1's] peer and physically assaulted peer by throwing a barrage of punches to peer's torso and head. Staff 2 and Staff 3 interfered and put Member in a physical hold to prevent Member from landing further punches. Staff 4 positioned [Staff 4] between Member and peer. Staff 1 and Staff 3 removed all other peers from the classroom. Staff 1 called TPD again at 1453 and notified Staff 1 that they would be enroute. Staff 1 contacted DCS guardian at 1504 but they did not answer so a voicemail was left. Member's probation officer was called at 1506 but also did not answer so a voicemail was left... Member Condition Before Incident: Member was alert and stirred up... Member Condition After Incident: Agitated... Medical Services Provided to Member Related to Incident: Member was assessed by residential RN, [E5], and was medically cleared... Medical Services Action: Guardian Contacted... Actions Taken and/or Recommended: Debrief with counseling with member/family, Debrief among staff and/or supervisors... Document Routing... Status: Pending... Approvers: [E5] RN, BHP-Staff (Pending)... [E11] BHT-Staff (Accepted)... [E9] BHPP-Staff (Accepted)... [E1] BHPP-Staff (Pending)..." 3. A review of R1's medical record revealed the incident involving the use of an emergency safety response on R1 (dated in October 2025) was not documented in the record within 24 hours after the incident occurred as required per R9-10-716.E.2.a-e and the facility's policies and procedures. 4. In an interview, E2 reported the incident involving an emergency safety response on R1 in October 2025 was not reported externally to the Arizona Health Care Cost Containment System (AHCCCS) Quality Management Portal because the facility determined it was not appropriate to submit to AHCCCS QM under the facility’s policies and procedures. 5. In an exit interview, the findings were reviewed with E1, E2, and E3, and no further documentation or comments were provided. This is a repeated violation from the on-site complaint investigation conducted on June 12, 2025.


summary: Complaint - 9/19/2025

raw_content: The following deficiencies were found during the on-site investigation of complaint 00145270 conducted on September 19, 2025:

rule: R9-10-703.G.2. Administration 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, record review, and interview, the administrator failed to ensure written notification was provided to the Department of a resident's self-injury within two working days after the resident inflicted self-injury or had an accident that required immediate intervention by an emergency medical services provider. The deficient practice posed a health and safety risk as the Department was unable to assess if there was an immediate health and safety concern for the other residents residing in the behavioral health residential facility.

findings: 1. A review of Department documentation, revealed a self-report dated September 17, 2025, submitted by an Intermountain Centers for Human Development personnel member. The document stated, "...Date/Time Observed: 9/13/2025 4:30 PM...[R1] was found lying on the floor in [R1's] room by [R1's] bed with a pair of leggings wrapped around [R1's] neck tightly, [R1's] face was observed being very red. Staff removed the leggings from [R1's] neck and tried to talk to [R1]. [R1] observed slightly mumbling and half conscious...[Fire Department] showed up at 1703 to assess [R1]..." 2. A review of the facility's incident reports revealed a document titled, "Incident, Accident, or Death Report," for R1 detailing the incident that was self-reported to the Department on September 17, 2025. The document stated, "...Date of Incident: 9/13/2025; Report Created: 9/17/2025..." 3. In an interview, E5 reported the facility had implemented a new computer system and all incident reports must be signed by several people before being submitted. E5 reported E5 had not signed off correctly and had to do it again which caused the delay. 4. In the exit interview, the findings were reviewed with E5 and E8 and no additional comments or documentation was provided. This is a repeat deficiency from inspections conducted on March 13, 2023, November 26, 2024, and December 18, 2024.

rule: R9-10-711.B.2.b. Resident Rights B. An administrator shall ensure that: 2. A resident is not subjected to: b. Neglect;

evidence: Based on documentation review and interview, the administrator failed to ensure a resident was not subjected to neglect. The deficient practice posed a health and safety risk as emergency personnel were not contacted in a timely manner after a resident had self-harmed.

findings: 1. A review of the facility's incident reports revealed a document titled, "Incident, Accident, or Death Report," dated September 17, 2025. The document stated, "...At approximately 1630 [R1] was found lying on the floor in [R1's] room by [R1's] bed with a pair of leggings wrapped around [R1's] neck tightly, [R1's] face was observed being very red.. Staff removed the leggings from [R1's] neck and tried to talk to [R1]. [R1] observed slightly mumbling and half conscious. On call notified at 1642, on call informed staff to call 911. 911 notified at 1644..." 2. In an interview, E5 acknowledged it took E1 fourteen minutes to contact 911 after finding R1 on the floor with leggings wrapped around R1's neck "slightly mumbling and half conscious." E5 reported E1 had been acting in accordance with the facility's policy by contacting on-call staff prior to 911. 3. In the exit interview, the findings were review with E5 and E8 and no additional comments or documentation were provided.

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, observation, 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 health and safety risk as a resident under the age of 18 engaged in self-harm.

findings: 1. A review of the facility's incident reports revealed a document titled, " Incident, Accident, or Death Report," dated September 17, 2025. The document stated, "...Staff was setting up laptop for 1700 medications at 1625. Staff went to [R1's] room to get [R1] for scheduled medications. At approximately 1630 [R1] was found lying on the floor in [R1's] room by [R1's] bed with a pair of leggings wrapped around [R1's] neck tightly, [R1's] face was observed being very red.. Staff removed the leggings from [R1's] neck and tried to talk to [R1]. [R1] observed slightly mumbling and half conscious. On call notified at 1642, on call informed staff to call 911. 911 notified at 1644. Staff observed [R1] breathing very slowly and lightly shook [R1] and lightly gave [R1] a sternum rub to make [R1] more conscious. [R1] continued to breathe slowly with eyes barely open, [R1] only responded to questions from staff by mumbling. [R1] was then observed coughing intermittently...[R1] stated, 'my throat hurts, my breathing hurts.' Staff reassured [R1] that emergency services would be coming to assess [R1]. [Fire Department] showed up at approximately 1703 to assess [R1]...[R1] stated, 'I wrapped my leggings around my neck, I was trying to kill myself.' ...[R1] transported to [hospital]...Witnesses:...[E1]..." 2. In an interview, E5 reported the staff on shift at the time of the incident were E1 and E12. 3. During a facility tour, E5 showed the Compliance Officers R1's room located towards the end of the hall where R1 had been found with leggings wrapped around R1's neck. E5 explained that when two staff are on shift, one will usually be at the front of the hall by the staff desk and the other will sit on a bench and make rounds periodically to check on residents every few minutes. 4. In an interview, E5 acknowledged R1 was not in the presence of the facility's personnel at the time of the incident, and therefore not provided with continuous protective oversight. 5. In the exit interview, the findings were reviewed with E5 and E8 and no further comments or documentation were provided. This is a repeat deficiency from an inspection conducted on May 3, 2024.


summary: Complaint - 9/12/2025

raw_content: The following deficiencies were found during the on-site investigation of complaints 00144686, 00144715, and 00144726 conducted on September 12, 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 documentation review, record review, and interview, the administrator failed to ensure sufficient personnel members were present on the behavioral health residential facility's premises with the qualifications, experience, skills, and knowledge necessary to ensure the health and safety of a resident. The deficient practice posed a health and safety risk as there was not enough trained personnel to safely manage the sudden, intense, or out-of-control behavior of two residents simultaneously.

findings: 1. A review of documentation revealed a document titled, "Incident, Accident, or Death Report," for R2 dated September 9, 2025 at 7:00 PM. The document stated, "...[R2] began escalating around 7:00pm - [R2] reported hearing voices, [R2] sobbing to the extent of being red in the face, screaming at voices to stop and covering ears. Staff attempted to calm [R2] by sitting with [R2]...but this was unsuccessful. Crisis team contacted at 7:26pm for [R2] and peer. While staff dealing with a separate peer crisis, [R2] began hitting the back of [R2's] head against the hallway wall while sitting on the bench. As soon as staff hear [sic] the noise, staff ran to [R2] and placed their hand between [R2's] head and the wall - in response [R2] began hitting [R2's] self on the forehead and top of [R2's] hard [sic] very hard with both hands in fists. Staff attempted to block [R2] by putting their hand in front of [R2's] head but [R2] responded by going around staffs hand...staff made the call to put [R2] in a one person safety hold for just under two minutes...Upon [R2] halting to get out of hold, staff released hold and hovered their hands over the [R2's] hands in safety check position...[R2] did not attempt to hit [R2's] self so staff released safety check position. Staff continued to sit next to [R2] on bench until [R2] could contract for safety. Crisis team was cancelled for [R2] at 7:57pm as [R2] had de-escalated..." The document stated the "witness" was E1. 2. A review of documentation revealed a document titled, "Incident, Accident, or Death Report," for R3 dated September 9, 2025 at 7:00 PM. The document stated, "...[R3] was triggered after experiencing crisis of peer. [R3] was in [R3's] bedroom sitting under closet shelf. Right around 7:00pm staff heard banging noises from [R3's] room upon which two staff hurried to [R3's] room...The noise was [R3] banging the back of [R3's] head into wall...staff quickly went to [R3] (one staff on either side of [R3]) and one staff put their hand between [R3's] head and the wall to prevent further head hitting behavior, [R3] responded by putting one of [R3's] hands around [R3's] throat in an attempt to choke [R3's] self. One staff removed [R3's] hand from [R3's] throat and hovered above that hand in safety check position. [R3] responded to this by wrapping [R3's] other hand around [R3's] throat in a second attempt to choke [R3's] self while also removing the original hand from safety check position and moving it towards [R3's] throat as well. A third staff member contacted crisis team at 7:26pm for [R3] and peer also experiencing crisis. Staff made the call to put [R3] in a two-person safety hold, which [R3] responded to by resuming banging the back of [R3's] head against the wall. One staff put their available hand in between [R3's] head and the wall. [R3's] responded to this by hitting the top of [R3's] head against shelf. [R3] continuously made attempts to get out of two-person safety hold several times via squirming, twisting, and thrashing - each time [R3] maneuvered out of two-person safety hold, [R3] resumed forcefully hitting [R3's]self in the head in various places as well as clawing at [R3's] arms and thighs...[R3] was immediately returned to two-person safety hold as [R3] was posing a large danger to [R3's] self. Due to [R3] continuously swapping between hitting [R3's] head against the wall and the shelf while in a two-person safety hold and with staff attempting to block head hitting via placing available hands between wall/shelf and head, staff made the call to carefully scoot [R3] out from under shelf in closet and staff was successful in doing so. Shortly before five minutes elapsed [R3] halted all attempts to maneuver out of hold or harm self, upon which staff released hold and entered safety check positions. While in safety check position [R3] resumed attempting to harm [R3's] self by choking [R3's] self, clawing at [R3's] arms and thighs, hitting [R3's] self in the head with fists, attempting to hit [R3's] head on the tile, and now attempting to knee [R3's] self in the head...staff called for additional help upon which a third staff member rushed to the scene to put [R3's] legs in safety hold - [R3] was placed in three-person safety hold. Upon re-entering safety hold [R3] was [sic] resumed attempting to squirm, thrash, and twist out of hold, as well as trying to scoot away in an attempt to hit [R3's] head on the floor. To prevent [R3] from hitting [R3's] head on the floor staff alternated between carefully scooting the [R3] back and closer to staff, staff placing their thigh between [R3's] head and the floor and utilizing any available soft items...to block [R3] from hitting [R3's] head on the floor. [Police Department] called, [R3] transported to [hospital]..." The document stated the "witnesses" were E1, E3, and E4. 3. A review of E3's personnel record revealed documentation of emergency safety response training titled, "CPI Blue Card," for E3. The document stated E3's emergency safety response training expired on April 12, 2020. 4. In an interview, E7 and E8 reported the incidents regarding R2 and R3 happened separately but at the same time. E7 reported R3 was "triggered" when another resident was being discharged, which prompted the incident. E7 reported R3 went to R3's room and began banging R3's head against the ground and the wall. E1 came in and put their hand behind R3's head to try to calm R3 down, but R3 would not stop banging R3's head. E1 called for assistance and E3 and E4 came to assist and put R3 in a two-person safety hold. R3 tried to get out of the hold multiple times and each time kept trying to hit R3's head. After about five minutes R3 halted all movement and the two staff went into a safety check position, where their hands were not on R3 but they were ready to put R3 in a safety hold again, if needed. E7 reported R3 then tried to knee themselves in the head and that was when E1, E3, and E4 put R3 in a three-person safety hold. 5. In an interview, E7 and E8 reported R2 was "triggered" by R3's incident and began saying R2 was hearing voices. E7 reported E1 tried to calm R2 down but was unsuccessful, and R2 started banging their head against the wall. E7 reported E1 performed a one-person safety hold at this time with R2 for about two minutes, until R2 could contract for safety. 6. In an interview, E7 reported the residents had disclosed to E7 they get "triggered" when one of their peers is being discharged. E7 reported the facility's normal process during a discharge consisted of a resident being strapped to a gurney and transported, and this is done in the presence of the other residents. E7 reported that since the incidents on September 9, 2025 with R2 and R3, and a separate incident later the same evening involving R1, E7 had changed the facility's process regarding discharges. E7 reported discharges will now occur in a separate area away from other residents. E7 also reported seeing trends that incidents such as these appear to happen during shift changes. E7 reported E7 has also adjusted the facility's personnel schedules to have more personnel present and overlapping during these shift change times. 7. In an interview, E11 reported the facility could not find any updated documentation E3 had current training in emergency safety response. 8. In the exit interview, the findings were discussed with E7 and E10 and no further comments or documentation were provided.

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 health and safety risk as a resident under the age of 18 engaged in self-harm.

findings: 1. A review of documentation revealed a document titled, "Incident, Accident or Death Report," for R1 dated September 9, 2025 at 9:23 PM. The document stated, "...Staff informed...[R1] attempted suicide by choking [R1's] self with a shirt to the point [R1] was unconscious [sic] staff immediately called 911. Staff explained that the incident occurred after [R1's] peer was being moved to CRC...[R1] became upset leading [R1] to thoughts about when [R1] would be going home...[R1] went to [R1's] room and shortly after [R1] was found on the floor unconscious with a shirt tight around [R1's] neck. [Police Department] was already on site because of another incident...[R1] was transported to [hospital]...[R1] moved to a higher level of care for now..." 2. A review of R1's medical record revealed a discharge summary dated September 9, 2025. The document stated, "...Member attempted to self-harm using a bed sheet to choke [R1's] self. Was found by staff, who contacted [emergency services], member was transported to [hospital]...where [R1] continued to express SI with plan and intent..." 3. In an interview, E7 reported around 9:00 PM on September 9, 2025 R1 was "triggered" by another resident being discharged. E7 reported R1 went to R1's room and about two to three minutes later, E1 found R1 unconscious on the floor with a shirt tied around R1's neck. E7 reported E1 immediately called 911, removed the shirt, and checked to see if R1 was breathing. E7 reported EMS took R1 to [hospital] and R1 was transferred to a higher level of care. 4. In an interview, E7 acknowledged R1 was not in the presence of the facility's personnel at the time of the incident, and therefore not provided with continuous protective oversight. 5. In the exit interview, the findings were reviewed with E7 and E10 and no further comments or documentation were provided. This is a repeat citation from inspection conducted on March 25, 2025, July 15, 2024 and May 3, 2024.

rule: R9-10-716.E.1.a.i. Behavioral Health Services E. An administrator shall ensure that: 1. An emergency safety response is: a. Only used: i. By a personnel member trained to use an emergency safety response,

evidence: Based on record review and interview, the administrator failed to ensure an emergency safety response was only used by a personnel member trained to use an emergency safety response. The deficient practice posed a potential health and safety risk as staff not properly trained in emergency safety response could cause unintended harm to a resident.

findings: 1. A review of the facility's incident reports revealed a document titled, "Incident, Accident, or Death Report," for R3 dated September 9, 2025 at 7:00 PM. The incident report contained documentation of a three-person safety hold involving R3, E1, E3, and E4. 2. A review of E3's personnel record revealed documentation of emergency safety response training titled, "CPI Blue Card," for E3. The document stated E3's emergency safety response training expired on April 12, 2020. 3. In an interview, E7 reported a three-person safety hold was used on R3 after several failed attempts at a one-person and two-person safety hold. E7 reported R3 tried to knee themselves in the head and that was when E1, E3, and E4 provided a three-person safety hold for R3. 4. In an interview, E11 reported the facility could not find any updated documentation E3 had current training in emergency safety response. 5. In the exit interview, the findings were discussed with E7 and E10 and no further comments or documentation were provided.


summary: Complaint - 9/4/2025

raw_content: The following deficiency was found during the on-site  investigation of complaint 00143025 conducted on September 4, 2025:

rule: R9-10-711.B.1. Resident Rights 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, for one of two residents sampled. The deficient practice posed a risk as the repeated violation shows a pattern of non-compliance to ensure the health and safety of residents.

findings: 1. A review of facility documentation revealed an incident report (dated in August 2025). The report stated, "[R2] walked over to [R1] who had been in crisis, picked up food off the floor and threw it at [R1]. [R1] hesitantly threw a piece of food back at [R2] and [R2] began to throw a barrage of punches at the head area of [R1]. [R2] and [R1] were separated, and [R2] was taken out of the [multipurpose room.] Crisis Mobile was called to come assess at 1759. Directly after [R2] asked to go to [R2's] room, but then came out with [two] peers and they were talking in the hallway, despite being told to go to their rooms. [R2] apologized to [R1 who] she attacked in the [multipurpose room]..." 2. In a joint interview, E5 and E6 confirmed R2 physically assaulted R1. They reported Tucson Police Department was notified. 3. A review of facility documentation revealed an incident report (dated in August 2025). The report stated, "...[E1] left ICHD [Intermountain Centers for Human Development] Desert River at [approximately] 1350 to transport [R1] to NextCare Urgent Care at 2460 Swan Rd to be evaluated after [R1] complained of being dizzy. [R1] had been physically assaulted by [R2] the night before. [R2] hit [R1] several times with a closed fist on [R1's] head. At NextCare Urgent Care, [R1] was evaluated by [a doctor]. [R1] reported having a headache and experiencing sensitivity to bright lights. [The doctor] recommended [R1] be further evaluated at [Emergency Department]. [E1] then transported [R1] to [Tucson Medical Center Pediatric Emergency Department]...where [R1] was evaluated by [a doctor]. After a series of tests, [the doctor] concluded [R1] had a concussion..." 4. In an exit interview, the findings were discussed with E5 and E6. They indicated facility personnel members intervened immediately after the altercation ensued and followed up with medical care for R1 when R1 reported symptoms and requested medical care. This is a repeat violation from the complaint investigations conducted on May 3, 2024; June 12, 2025; and August 21, 2025.


summary: Complaint - 8/21/2025

raw_content: The following deficiency was found during the on-site  investigation of complaints 00141735, 00141751 and 00141867 conducted on August 21, 2025:

evidence: Based on documentation review and interview, the administrator failed to ensure a resident was treated with dignity, respect, and consideration.

findings: 1. A review of facility documentation revealed a document titled "Incident Accident or Death Report," dated August 20, 2025, for R1. The document stated "On 8/[day]/2025 at 1609 hrs, the member escalated during fitness block due to frustration with game rules, leading to a verbal dispute. At 1613 hrs, a peer struck the member, and the member struck back in the MPR [multipurpose room.] At 1615 hrs, the member threw a trash can that broke, attempting to use the pieces as weapons. The member also grabbed a pencil from the classroom and used it as a weapon, refusing staff directives to drop it. Writer and four staff intervened using verbal de-escalation and redirection...At 1737 hrs, the member attempted to attack a peer. The counselor implemented a Safety Care hold to prevent assault." 2. A review of facility documentation revealed a document titled "Incident Accident or Death Report," dated August 20, 2025, for R2. The document stated, "On 8/[day]/2025 at 1609 hrs, during fitness block, [R1] escalated due to frustration with the game rules. This member made verbal comments toward the peer, which led to a verbal dispute. At 1613, the member struck [R1] and the peer immediately struck [R2] back in the MPR. During the physical altercation, [R1] caused a visible mark on [R2's] forehead, which began bleeding. At 1615 hrs, [R1] threw a trash can that broke, attempting to use the pieces as weapons..." 3. In an exit interview, the findings were reviewed with E1 and E2 and no additional comments were made or documentation provided.


summary: Complaint - 6/12/2025

raw_content: The following deficiencies were found during the on-site investigation of complaint 00132134 conducted on June 12, 2025:

rule: A.R.S. § 36-420.01.A. Health care institutions; fall prevention and fall recovery; training programs; definition A. Each health care institution shall develop 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 and record review, the administrator failed to administer a training program for all staff regarding fall prevention and fall recovery to include initial training in fall prevention and fall recovery, for one of eight personnel members sampled. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not implemented, and the repeat violation shows a pattern of non-compliance to ensure the health and safety of residents.

findings: R9-10-101.167. “Personnel member” means, except as defined in specific Articles in this Chapter and excluding a medical staff member, a student, or an intern, an individual providing physical health services or behavioral health services to a patient. 1. A review of facility documentation revealed an undated fall prevention and fall recovery training program titled “Preventing Falls.” 3. A review of E8’s (hired in February 2025 as a behavioral health technician) personnel record revealed no initial training in fall prevention and fall recovery. 4. In an interview, E1 reported E8 was not considered personnel members but rather a contracted employee from a staffing agency. E1 reported contracted employees did not have access to Relias, where the fall prevention and fall recovery training was completed. E1 reported the staffing agency “Altra” provided the facility with a personnel record. E1 acknowledged personnel members who provide behavioral health services to residents, including contracted personnel members, were required to have initial training in fall prevention and fall recovery. 5. In an exit interview, the findings were discussed with E1, E2, E3 (virtually), and E4 (virtually) and no additional statements or documentation were provided. This is a repeat violation from the compliance inspection and complaint investigation completed on July 11, 2024.

evidence: Based on documentation review, record review, and interview, the administrator failed to implement policies and procedures to protect the health and safety of residents to cover emergency safety responses. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of personnel members and those standards were not complied with.

findings: 1. A review of facility documentation revealed a policy and procedure, dated in May 2024, titled “Emergency Safety Response.” The policy stated “Within 24 hours after an emergency safety response is used for a member, the following information is entered into the member’s medical record: a. The date and time the emergency safety response was used; b. The name of each staff member who used an emergency safety response; c. The specific emergency safety response used; d. The staff member or member behavior, event, or environmental factor that caused the need for the emergency safety response; and e. Any injury that resulted from the emergency safety response.” 2. A review of facility documentation revealed an incident report, dated in May 2025, revealed an emergency safety response was used on R1 in May 2025. 3. A review of R1’s (admitted in May 2025) medical record revealed no documentation to include the date and time the emergency safety response was used; the name of each staff member who used an emergency safety response; the specific emergency safety response used; the staff member or member behavior, event, or environmental factor that caused the need for the emergency safety response; and any injury that resulted from the emergency safety response. 4. In an interview, E1 reported E2 was directly involved in the emergency safety response implemented on R1. 5. In an interview, E2 reported E2 attempted two emergency safety holds and was unsuccessful on both attempts. E2 reported E2 utilized a bite release hold on R1 and was successful. E2 acknowledged each attempt was not documented in the medical record. 6. In a joint interview, E1 and E2 acknowledged the emergency safety response policy and procedure was not implemented. 7. In an exit interview, the findings were discussed with E1, E2, E3 (virtually) and E4 (virtually) and no additional statements or documentation were provided.

rule: R9-10-703.C.2.t. Administration C. An administrator shall ensure that: 2. Policies and procedures for behavioral health services and physical health services are established, documented, and implemented to protect the health and safety of a resident that: t. Cover how the behavioral health residential facility will respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual;

evidence: Based on documentation review and interview, the administrator failed to implement policies and procedures to protect the health and safety of a resident to cover how the behavioral health residential facility would respond to a resident’s sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of personnel members and these standards were not complied with.

findings: 1. A review of facility documentation revealed a policy and procedure, dated in May 2024, titled “Behavior Management Techniques.” The policy stated “If an individual engages in a sudden, unanticipated and out-of-control aggressive or destructive behavior, which is endangering the health or safety of the individual or another individual, the following shall be done: a. Staff will initially utilize preventative interventions which may include, but are not limited to the following techniques: b. Calm request to cease behavior. c. Calm redirection to a more desirable (to the community) task or activity. d. Removing other individuals from the immediate area. e. Removing any potentially dangerous objects from the immediate area. f. Utilization of a novel, distracting and interrupting stimuli. g. Defensive positioning. h. Calling for assistance…” 2. A review of facility documentation revealed security camera footage, dated in June 2025. The footage revealed R4 was physically attacked by R5 while E5 was present in the room. The footage revealed R4 was backed into the wall on multiple occasions while E5 followed behind R5. E5 was seen attempting to place themselves between R4 and R5 but was unsuccessful on multiple occasions. The footage also revealed at least three residents, who were not involved, watched R5 attack R4. R5 was seen, at one point, leaving the room and re-entering the room to continue attacking R4. The security footage revealed E5 did not request R5 to cease attacking R4, to redirect R5, to remove stimuli, to use defensive positioning, or call for assistance. 3. In a joint interview, E1 and E2 reported this was the first they had seen the security camera footage. E1 and E2 acknowledged, after watching the camera footage, E5 did not appear to implement the sudden, intense, or out-of-control behavior policy and procedure. 4. In an exit interview, the findings were discussed with E1, E2, E3 (virtually), and E4 (virtually) and no additional statements or documentation were provided.

evidence: Based on observation and interview, the administrator failed to ensure a resident was treated with dignity, respect, and consideration. The deficient practice posed a risk as the repeat violation shows a pattern of noncompliance to ensure the health and safety of residents.

findings: 1. The Compliance Officer observed locked bathrooms. 2. In an interview, R3 stated “You have to wait,” in regards to using the facility bathroom. R3 reported residents are unsure where staff are at night. R3 stated R3 “had issues at night time finding staff and getting [hygiene products].” 3. In an interview, R6 reported staff were hard to find at night to use the bathroom. 4. In a joint interview, E1 and E2 reported bathrooms were locked for the safety of residents and residents were never refused to use the bathroom. E1 and E2 acknowledged residents waiting to use the bathroom, and waiting for hygiene products, while struggling to find a personnel member was not treating residents with dignity, respect, and consideration. 5. A review of facility documentation revealed security camera footage, dated in June 2025. The footage revealed R4 was physically attacked by R5 while E5 was present in the room. The footage revealed R4 was backed into the wall on multiple occasions while E5 followed behind R5. E5 was seen attempting to place themselves between R4 and R5 but was unsuccessful on multiple occasions. The footage also revealed at least three residents, who were not involved, watched R5 attack R4. R5 was seen, at one point, leaving the room and re-entering the room to continue attacking R4. 6. In an interview, R4 reported R4 was hurt after the incident with R5 and R4’s neck hurt and R4 had a scratch on R4’s finger. R4 reported R5 hit R4 in the head three (3) times. R4 reported R4 did not receive medical attention or seen by the registered nurse. 7. In a joint interview, E1 and E2 acknowledged R4 was not treated with dignity, respect, and consideration as R5 was allowed to continued to assault R4 in front of personnel members and R4 was injured and did not receive medical attention or evaluated by the registered nurse. E1 and E2 acknowledged R4 was not treated with dignity, respect, and consideration as residents who were not involved in the altercation were bystanders and watched the altercation without attempting to be removed from the area. 8. In an exit interview, the findings were discussed with E1, E2, E3 (virtually), and E4 (virtually) and no additional statements or documentation were provided. This is a repeat violation from the complaint inspection completed on May 3, 2024.

rule: R9-10-711.B.3.b. Resident Rights B. An administrator shall ensure that: 3. Except as provided in subsection (C) or (D), and unless restricted by the resident's representative, a resident is allowed to: b. Have privacy in correspondence, communication, visitation, financial affairs, and personal hygiene; and

evidence: Based on observation, record review, and interview, the administrator failed to ensure a resident was allowed to have privacy in communication and visitation.

findings: 1. The Compliance Officers observed a conference room with a security camera installed. 2. In an interview, E2 reported residents met with visitors in the conference room. E2 acknowledged residents did not receive privacy in visitation. 3. In an interview, R4 stated personnel members listen to resident phone calls on speaker phone in "the bubble." 4. In an interview, E2 reported residents may be required to have their phone calls monitored if residents have outbursts or are triggered on certain phone calls. E2 acknowledged unless clearly indicated in the resident’s treatment plan, residents have the right to receive privacy in communication. 5. A review of R4's (admitted in April 2025) medical record revealed R4's treatment plan, dated in April 2025. However, the treatment plan did not include documentation to restrict R4's ability to have privacy in communication, per R9-10-711(D). 6. In an exit interview, the findings were discussed with E1, E2, E3 (virtually), and E4 (virtually) and no additional statements or documentation were provided.

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 record review and interview, the administrator failed to ensure a resident did not share any space, or verbally or physically interact with any other resident who posed a threat to the resident’s health or safety based on the other resident's documented diagnosis. The deficient practice posed a risk as R5 physically attacked R4.

findings: 1. A review of facility documentation revealed security camera footage, dated in June 2025. The footage revealed R4 was physically attacked by R5 while E5 was present in the room. The footage revealed R4 was backed into the wall on multiple occasions while E5 followed behind R5. E5 was seen attempting to place themselves between R4 and R5 but was unsuccessful on multiple occasions. The footage also revealed at least three residents, who were not involved, watched R5 attack R4. R5 was seen, at one point, leaving the room and re-entering the room to continue attacking R4. 2. A review of R5’s (admitted in April 2025) medical record revealed R5’s behavioral health assessment, dated in April 2024. R5’s assessment stated “Mother shared that members suicidal behaviors include statements stating that [R5] has shared that ‘[R5] does not want to live past 18yo [sic]’ and homicidal behaviors include consistent thoughts of wanting to ‘kill us’ and ‘has jumped out of a window’ due to thoughts of wanting to harm [R5’s] brothers. Member has acted upon HI [homicidal ideations] towards brothers, to include chasing brother with a baseball bat stating that member reported ‘I would have killed him if I caught up to him.” Mother shared additionally incidents include holding a pillow over [R5’s] older brothers face to the point where brother began ‘struggling and waking up’…” 3. In an interview, R4 reported R4 felt unsafe due to the incident. 4. In a joint interview, E1 and E2 reported this was the first they had seen the camera footage. E1 and E2 acknowledged, after watching the camera footage, R4 was allowed to share a space with R5 and R5 had a history of violence and homicidal ideations. 5. In an exit interview, the findings were discussed with E1, E2, E3 (virtually), and E4 (virtually) and no additional statements or documentation were provided.

rule: R9-10-716.E.2.a. Behavioral Health Services E. An administrator shall ensure that: 2. Within 24 hours after an emergency safety response is used for a resident, the following information is entered into the resident medical record: a. The date and time the emergency safety response was used;

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure within 24 hours after an emergency safety response was used for a resident, the date and time the emergency safety response was used was entered into the resident record, for one of four resident records sampled.

findings: 1. A review of facility documentation revealed an incident report, dated in May 2025, revealed an emergency safety response was used on R1 in May 2025. 2. A review of R1’s (admitted in May 2025) medical record revealed no documentation to include the date and time the emergency safety response was used. 3. In an interview, E2 reported E2 attempted two emergency safety holds and was unsuccessful on both attempts. E2 reported E2 utilized a bite release hold on R1 and was successful. 4. In a joint interview, E1 and E2 acknowledged R1’s medical record did not include documentation of the date and time the emergency safety response was used. 5. In an exit interview, the findings were discussed with E1, E2, E3 (virtually) and E4 (virtually) and no additional statements or documentation were provided.

rule: R9-10-716.E.2.b. Behavioral Health Services E. An administrator shall ensure that: 2. Within 24 hours after an emergency safety response is used for a resident, the following information is entered into the resident medical record: b. The name of each personnel member who used an emergency safety response;

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure within 24 hours after an emergency safety response was used for a resident, the name of each personnel member who used an emergency safety response was entered into the resident record, for one of four resident records sampled.

findings: 1. A review of facility documentation revealed an incident report, dated in May 2025, revealed an emergency safety response was used on R1 in May 2025. 2. A review of R1’s (admitted in May 2025) medical record revealed no documentation to include the name of each personnel member who used an emergency safety response on R1 in May 2025. 3. In an interview, E2 reported E2 attempted two emergency safety holds and was unsuccessful on both attempts. E2 reported E2 utilized a bite release hold on R1 and was successful. 4. In a joint interview, E1 and E2 acknowledged R1’s medical record did not include documentation of each personnel member who used an emergency safety response on R1. 5. In an exit interview, the findings were discussed with E1, E2, E3 (virtually) and E4 (virtually) and no additional statements or documentation were provided.

rule: R9-10-716.E.2.c. Behavioral Health Services E. An administrator shall ensure that: 2. Within 24 hours after an emergency safety response is used for a resident, the following information is entered into the resident medical record: c. The specific emergency safety response used;

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure within 24 hours after an emergency safety response was used for a resident, the specific emergency safety response used was entered into the resident record, for one of four resident records sampled.

findings: 1. A review of facility documentation revealed an incident report, dated in May 2025, revealed an emergency safety response was used on R1 in May 2025. 2. A review of R1’s (admitted in May 2025) medical record revealed no documentation to include the specific emergency safety response used on R1 in May 2025. 3. In an interview, E2 reported E2 attempted two emergency safety holds and was unsuccessful on both attempts. E2 reported E2 utilized a bite release hold on R1 and was successful. 4. In a joint interview, E1 and E2 acknowledged R1’s medical record did not include documentation of the specific emergency safety response used on R1 in May 2025. 5. In an exit interview, the findings were discussed with E1, E2, E3 (virtually) and E4 (virtually) and no additional statements or documentation were provided.

rule: R9-10-716.E.2.d. Behavioral Health Services E. An administrator shall ensure that: 2. Within 24 hours after an emergency safety response is used for a resident, the following information is entered into the resident medical record: d. The personnel member or resident behavior, event, or environmental factor that caused the need for the emergency safety response; and

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure within 24 hours after an emergency safety response was used for a resident, the personnel member or resident behavior, event, or environmental factor that caused the need for the emergency safety response was documented in the resident record, for one of four resident records sampled.

findings: 1. A review of facility documentation revealed an incident report, dated in May 2025, revealed an emergency safety response was used on R1 in May 2025. 2. A review of R1’s (admitted in May 2025) medical record revealed no documentation of the personnel member or resident behavior, event, or environmental factor that caused the need for the emergency safety response used on R1 in May 2025. 3. In an interview, E2 reported E2 attempted two emergency safety holds and was unsuccessful on both attempts. E2 reported E2 utilized a bite release hold on R1 and was successful. E2 reported R1 was upset as R1’s parents dropped R1 off at the facility and R1’s behavior escalated from there. 4. In a joint interview, E1 and E2 acknowledged R1’s medical record did not include documentation of the personnel member or resident behavior, event, or environmental factor that caused the need for the emergency safety response used on R1 in May 2025. 5. In an exit interview, the findings were discussed with E1, E2, E3 (virtually) and E4 (virtually) and no additional statements or documentation were provided.

rule: R9-10-716.E.2.e. Behavioral Health Services E. An administrator shall ensure that: 2. Within 24 hours after an emergency safety response is used for a resident, the following information is entered into the resident medical record: e. Any injury that resulted from the use of the emergency safety response;

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure within 24 hours after an emergency safety response was used for a resident, any injury that resulted from the use of the emergency safety response was documented in the resident record, for one of four resident records sampled.

findings: 1. A review of facility documentation revealed an incident report, dated in May 2025, revealed an emergency safety response was used on R1 in May 2025. 2. A review of R1’s (admitted in May 2025) medical record revealed no documentation of any injury that resulted from the use of the emergency safety response on R1 in May 2025. 3. In an interview, E2 reported E2 attempted two emergency safety holds and was unsuccessful on both attempts. E2 reported E2 utilized a bite release hold on R1 and was successful. E2 reported R1 did not sustain any injuries. 4. In a joint interview, E1 and E2 acknowledged R1’s medical record did not include documentation of any injury that resulted from the use of the emergency safety response used on R1 in May 2025. 5. In an exit interview, the findings were discussed with E1, E2, E3 (virtually) and E4 (virtually) and no additional statements or documentation were provided.


summary: Complaint - 5/27/2025

raw_content: An on-site investigation of complaint 131581 was conducted on May 27, 2025, and no deficiencies were cited:


summary: Complaint;Compliance (Annual) - 5/15/2025

raw_content: The following deficiencies were found during the on-site compliance inspection and investigation of complaints 00120929, 00129431, and 00130021 conducted on May 15, 2025:

inspection_type: Complaint;Compliance (Annual)

rule: R9-10-708.A.4.d. Treatment Plan A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that: 4. Includes: d. The date when the resident's treatment plan will be reviewed;

evidence: Based on record review and interview, the administrator failed to ensure a treatment plan for each resident included the date the treatment plan was to be reviewed, for two of three current residents sampled.

findings: 1. A review of R2's (admitted in 2025) medical record revealed a treatment plan (dated in March 2025). However, the treatment plan did not include the date the treatment plan was to be reviewed. 2. A review of R3's (admitted in 2025) medical record revealed a treatment plan (dated in February 2025). However, the treatment plan did not include the date the treatment plan was to be reviewed. 3. In a joint exit interview, E1 and E2 acknowledged R2's and R3's treatment plans did not include the date when R2's and R3's treatment plans would be reviewed.

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 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 R4's personal history. The deficient practice posed a risk as R4 had access to plastic pieces while admitted into a behavioral health residential facility in contradiction with their behavioral health issue.

findings: 1. A review of R4's (admitted in 2025) electronic medical record revealed a behavioral health assessment (dated in March 2025). The assessment stated " ...Member reported self-harm via cutting and shared they are 'superficial' cuts...Member reports that [R4] has struggled with SI/self-harm 'for a couple years maybe' and shared that self-harming has become more frequent with time..." 2. A review of R4's electronic medical record revealed an incident report (dated in May 2025). The incident report stated "...member had noticed a room search had been conducted earlier in the day with a result of staff removing items that could be used for self-harm after finding blood on members blankets...Staff then heard a bang and checked on member, member was standing by the wall. Staff asked member if [R4] was ok or needed anything but member did not reply...then let member know a shower was available and member got in the shower. After the shower another staff noticed pieces of what appeared to be plastic on the floor. Staff cleaned it all up and another staff pulled member aside and asked member to see [R4's] armes [sic] and empty out [R4's] pockets. Member refused and just stood there not speaking...staff did another room search in which blood was found on damp towels..." 3. In an interview, E1 reported it was unclear where the plastic came from as nothing was broken. 4. In a joint exit interview, E1 and E2 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 is a repeat violation from the on-site complaint investigation conducted on November 26, 2024 and the on-site complaint investigation conducted on August 20, 2024.

rule: R9-10-716.B.2. Behavioral Health Services B. An administrator shall ensure that counseling is: 2. Provided according to the frequency and number of hours identified in the resident's treatment plan, and

evidence: Based on record review and interview, the administrator failed to ensure counseling was provided according to the frequency and number of hours identified in the resident's treatment plan, for three of three current residents sampled. The deficient practice posed a risk a resident did not receive treatment to cure, improve, or palliate the resident’s behavioral health issue at the health care institution.

findings: 1. A review of R1's electronic medical record revealed a treatment plan dated in December 2024. The treatment plan indicated R1 to receive individual counseling 1-7 times a week for 1 hour each session. 2. A review of R1's electronic medical record revealed R1 received individual counseling on the following date: April 17, 2025, for one hour. However, no documentation to indicate R1 received individual counseling 1-7 times a week was available for review. 3. A review of R2's electronic medical record revealed a treatment plan dated in March 2025. The treatment plan indicated R2 to receive individual counseling 1-7 times a week for 1 hour each session. 4. A review of R2's electronic medical record revealed R2 received individual counseling on the following date: May 6, 2025, for one hour. However, no documentation to indicate R2 received individual counseling 1-7 times a week was available for review. 5. A review of R3's electronic medical record revealed a treatment plan dated in February 2025. The treatment plan indicated R3 to receive individual counseling 1-7 times a week for 1 hour each session. 6. A review of R3's electronic medical record revealed R3 received individual counseling on the following date: May 6, 2025, for one hour. However, no documentation to indicate R3 received individual counseling 1-7 times a week was available for review. 7. In a joint exit interview, E1 and E2 acknowledged counseling was not provided to R1, R2, and R3 according to the frequency and number of hours identified in R1's, R2's, and R3's treatment plans.

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 provided to a resident was in compliance with an order, for one of three current residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper assistance in the self-administration of medication.

findings: 1. A review of R1's electronic medical record revealed a medication order for "Clondine 0.1.mg...Take one (1) tablet..." 2. A review of R1's electronic medication administration record (MAR) revealed R1 did not receive assistance in the self-administration of "Clondine 0.1.mg...Take one (1) tablet..." on December 27, 2024 and December 28, 2024. 3. A review of R1's electronic medication administration record (MAR) revealed R1 received assistance in the self-administration of "Clondine 0.1.mg...Take one (1) tablet..." on December 30, 2024. However, the MAR revealed R1 received two tablets instead of one. 4. A review of R1's electronic medical record revealed an incident report dated in December 2024. The report stated "...Writer observed member taking 2 of [R1's] Clondine HCI ER 0.1mg tablets..." 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 - 3/25/2025

raw_content: The following deficiency was found during the on-site investigation of complaint 122965 conducted on March 25, 2025.

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 to the behavioral health residential facility with limited ability to function independently received continuous protective oversight.

findings: 1. A review of facility documentation revealed an incident report. The incident report stated “On the above date and time indicated, A mobile urgent care team came out to assess members hand as [R1] punched a wall again on 03/14/2025. Member complained of pain on the 15th and the mobile unit was scheduled. During assessment, urgent care mobile team took vitals, checked members range of motion ect and stated that there were no issues with muscle, tendons or ligaments and they were ordering another mobile x-ray team to come out on the 17th. Guardian was notified @ 1755 on the 16th and on call supervisor was notified directly after. Member was given follow up care instructions which were basically to keep 2 fingers buddy taped and get the x-rays completed to rule out any breakage to bones.” 2. A review of R1’s medical record revealed R1 had a guardian. 3. A review of R1’s medical record revealed a document titled “Shift Note” dated March 18, 2025. The document stated “...Member was taking down window clings form [sic] the windows, messing with the emergency lights and pushing up the ceiling tiles, Member eventually got a string from the sock [R1] was wearing and wrapped it around [R1’s] finger…Crisis mobile was called out and decided it was not necessary to take member to CRC or another facility. Member did bang [R1’s] head on the wall multiple times though…Member did bang/hit the wall during hygiene time as well as while [R1] was showering.” 4. In an interview, E2 reported on March 14, 2025, R1 punched the wall in R1’s bedroom. Additionally, on March 18, 2025, R1 self harmed by banging their head in R1's bedroom and in the shower area. E2 reported R1 is only put on a one to one when E2 begins to self harm. 5. In an exit interview, the findings were discussed with E1 and E2, and no additional statements or documentation were provided.