summary: Complaint;Compliance (Annual) - 11/22/2024

raw_content: The following deficiencies were found during the on-site compliance inspection and investigation of complaint #AZ00219054 conducted on November 22, 2024:

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

evidence: Based on documentation review, record review, and interview, the administrator failed to implement policies and procedures to protect the health and safety of a resident to cover cardiopulmonary resuscitation (CPR) training to include a demonstration of the individual's ability to perform cardiopulmonary resuscitation. The deficient practice posed a risk as the standards expected of employees were not followed.

findings: 1. A review of the facility's policies and procedures revealed a policy titled "POLICY REGARDING FIRST AID AND CPR TRAINING" dated October 21, 2024. The policy stated "Step Two Recovery Center ensures at least one personnel member at the facility is always First Aid and CPR certified. Each personnel member on an outing must be First Aid and CPR First aid and CPR training will be provided by the American Safety & Health Institute or equivalent and paid for by Step Two Recovery Center. This training includes a demonstration of the individual's ability to perform CPR. All required personnel must renew this certification every other year. Documentation of a personnel member's First Aid and CPR training will be kept in their personnel file and renewed as needed. 2. A review of the facility's daily staffing schedules revealed E3 worked the following dates and times: November 4, 2024 and November 10, 2024 from 12:00 to 9:00 (AM or PM was not indicated). 3. A review of E3's personnel record revealed documentation of both CPR and first aid training from American Academy of CPR & First Aid, Inc., issued on December 28, 2023 and May 29, 2024. 4. A review of the website "www.onlinecprcertification.net" stated "American Academy of CPR & First Aid, Inc...Online BLS CPR And Printable Certification Chest compression demo for bls cpr training Acquire the skills and knowledge you need to save the life of an adult, child, or infant with our free online BLS CPR training...Online First Aid Training And Printable Certification Upon completing our free online first aid course, you'll have the skills and knowledge to respond to adult, child, and infant emergencies..." 5. In a joint interview, E1 reported E3's CPR and first aid was done online, and a zoom video call demonstration was done online. E1 and E2 acknowledged E3's CPR training did not include a demonstration of the individual's ability to perform CPR and the policy and procedure was not implemented.

evidence: Based on documentation review, record review, and interview, the administrator failed to implement policies and procedures to protect the health and safety of a resident to cover dispensing medication. The deficient practice posed a risk as the facility's standards were not implemented and posed a risk if a resident experienced a change in condition due improper dispensing of a medication.

findings: 1. A review of the facility's policies and procedures revealed a policy titled "POLICY REGARDING ASSISTANCE IN THE SELF-ADMINISTRATION OF MEDICATION" dated November 20, 2024. The policy stated "The personnel member will observe the resident while the resident takes medication to ensure they are taking the dosage of medication stated on the medication container label or according to an order from a medical practitioner dated later than the date on the medication container label...The Personnel member will ensure that a drink is available to the Resident prior to the Resident entering the area where the medication will be taken." 2. A review of facility documentation revealed an incident report, dated November 20, 2024. The incident report stated "DESCRIPTION OF INCIDENT (Including events leading up to incident): On the morning of 11/19/2024 at approximately 12:45am [R1] reported to that [R1] had taken 14-17 Acetaminophen on the evening of 11/15/2024. Personnel member [E8] asked how [R1] obtained Acetaminophen pills. Resident stated, " I told [E6] that I had a headache and needed some Tylenol. When I went in to the room to take the medicine I didn't have a drink and there weren't any in the fridge. [E6] went into the back room to get me a bottle of water and when [E6] did, I poured some of the pills in my hand when [E6] wasn't in the room with me. Then I took them later that night." Personnel asked [R1] why [R1] took the acetaminophen and [R1] reported that [R1] tried to kill [R1]. [R1] reported to Personnel that, that was [R1's] first ever suicide attempt and that [R1] had been struggling with suicidal ideation for the past two weeks. Personnel asked [R1] if [R1] was currently suicidal or had any intent to hurt [R1]. [R1] said [R1] was not suicidal and had no intent to harm [R1] and committed to Personnel that, although [R1] did not feel good, [R1] was stable and safe..." 3. In a joint interview, E1 reported E6 gave R1 a bottle of Acetaminophen, and E6 left R1 unattended to get water from another room. E1 reported E6's employment was terminated after the incident. E1 and E2 acknowledged policies and procedures to protect the health and safety of a resident to cover dispensing medication were not implemented.

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure sufficient personnel members were present on a behavioral health residential facility's premises with the qualifications, experience, skills, and knowledge necessary to meet the needs of a resident, and ensure the health and safety of a resident. The deficient practice posed a risk if the facility was unable to meet the needs of the residents and ensure the resident's health and safety.

findings: 1. A review of facility documentation revealed an incident report, dated November 20, 2024. The incident report stated "DESCRIPTION OF INCIDENT (Including events leading up to incident): On the morning of 11/19/2024 at approximately 12:45am [R1] reported that [R1] had taken 14-17 Acetaminophen on the evening of 11/15/2024. Personnel member [E8] asked how [R1] obtained Acetaminophen pills. Resident stated, " I told [E6] that I had a headache and needed some Tylenol. When I went in to the room to take the medicine I didn't have a drink and there weren't any in the fridge. [E6] went into the back room to get me a bottle of water and when [E6] did, I poured some of the pills in my hand when [E6] wasn't in the room with me. Then I took them later that night." Personnel asked [R1] why [R1] took the acetaminophen and [R1] reported that [R1] tried to kill [R1]. [R1] reported to Personnel that, that was [R1's] first ever suicide attempt and that [R1] had been struggling with suicidal ideation for the past two weeks. Personnel asked [R1] if [R1] was currently suicidal or had any intent to hurt [R1]. [R1] said [R1] was not suicidal and had no intent to harm [R1] and committed to Personnel that, although [R1] did not feel good, [R1] was stable and safe..." 2. In a joint interview, E1 reported E6 gave R1 a bottle of Acetaminophen, and E6 left R1 unattended to get water from another room. E1 and E2 acknowledged sufficient personnel members were not present at the behavioral health residential facility's premises to meet the needs of the residents and ensure the health and safety of the residents.

evidence: Based on record review and interview, the administrator failed to ensure a treatment plan was developed for each resident to include the signature of the resident or the resident's representative, and date signed, or documentation of the refusal to sign, for one of four residents sampled.

findings: 1. A review of R1's medical record revealed a current treatment plan (dated in 2024). The document was signed by R1, however, the signature R1's representative, and date signed, or documentation of the refusal to sign was not available for review. 2. In a joint interview, E1 and E2 acknowledged R1's treatment plan did not include the signature of R1's representative, and date signed, or documentation of the refusal to sign.

evidence: Based on record review and interview, the administrator failed to ensure a medical record contained documented informed consent for treatment by the resident's representative, for three of four residents sampled. The deficient practice posed a risk if residents were provided a diagnostic procedure without a representative's consent.

findings: R9-10-101.114.b "Informed consent" means "Obtaining documented authorization for the proposed treatment, surgical procedure, psychotropic drug medication, opioid, or diagnostic procedure from the patient or the patient ' s representative." 1. A review of Department documentation revealed BH2607 was licensed as a behavioral health residential facility to provide services to individuals under the age of 18. 2. A review of R1's medical record revealed a document titled "TB Skin Test and Consent Form" dated November 7, 2024. The document stated "I have received information about the TB Skin Test. I have had a chance to ask questions, which were answered to my satisfaction. I agree to return in 48 - 72 hours to have the TB Skin Test read. I understand the skin test cannot be read prior to 48 hours or later than 72 hours using both the Date AND Time of test administration. A TB Skin Test read outside these parameters are not within CDC standards and will require repeat testing. I understand the risk and benefits of the TB Skin Test and request that the test be given to me. If l am symptomatic for TB or if the TB Skin Test is positive, results may be communicated to the provider with whom I will follow up, if medical care is needed. I understand that if this test is being obtained for employment purposes, my results may be communicated to the employer." However, the document contained R1's signature, and did not include R1's representative ' s signature. 3. A review of R3's medical record revealed a document titled "TB Skin Test and Consent Form" dated October 31, 2024. The document stated "I have received information about the TB Skin Test. I have had a chance to ask questions, which were answered to my satisfaction. I agree to return in 48 - 72 hours to have the TB Skin Test read. I understand the skin test cannot be read prior to 48 hours or later than 72 hours using both the Date AND Time of test administration. A TB Skin Test read outside these parameters are not within CDC standards and will require repeat testing. I understand the risk and benefits of the TB Skin Test and request that the test be given to me. If l am symptomatic for TB or if the TB Skin Test is positive, results may be communicated to the provider with whom I will follow up, if medical care is needed. I understand that if this test is being obtained for employment purposes, my results may be communicated to the employer." However, the document contained R3's signature, and did not include R3's representative's signature. 4. A review of R4's medical record revealed a document titled "TB Screening Questionnaire" dated October 29, 2024. The document stated "All patients presenting for TB screening or clearance must complete this questionnaire (e.g., PPD, QFT, or Questionnaire)" Additionally, the document stated "RISK ASSESSMENT" and included questions for TB risk assessment. The document included a signature line which stated "I have answered the above question to the best of my knowledge and understand my answers will be used for my medical evaluation." However, the document contained R4's signature, and did not include R4's representative's signature. 5. A review of R1's, R3's, and R4's medical records revealed a document titled "GENERAL/INFORMED CONSENT." The documents stated "The specific treatment being proposed; The nature and purpose of services provided by the STEP TWO RECOVERY CENTER, any potential risks involved (including not proceeding with the proposed services), and any alternative treatments or services available; Who will perform each treatment or service and their qualifications; The cost of treatment, including pre-admission and post-discharge treatment or The expectations for resident participation; STEP TWO RECOVERY CENTER's Ground Rules; STEP TWO RECOVERY CENTER's Grievance Procedure Order of Acetaminophen and Ibuprofen by STRC Personnel; My consent is voluntary and may be withheld or withdrawn at any time; I have received and understand the above information and give my general consent to treatment." The documents were signed by both R1, R3, and R4, and R1's, R3's and R4's representatives. However, the documents did not include documented authorization for a diagnostic procedure. 6. In a joint interview, E1 and E2 reported to believe the "GENERAL/INFORMED CONSENT" signed by the resident's representatives upon admission, was sufficient for informed consent, and would be acceptable as an informed consent for TB skin tests and assessments. E1 reported to be unaware that R1, R3, and R4 were unable to sign a document to give consent for a diagnostic procedure such as a TB skin test and assessment. Further comment was not provided.

evidence: Based on record review and interview, the administrator failed to ensure a resident's treatment plan included the frequency and number of hours counseling was to be provided, for four of four residents sampled. The deficient practice posed a risk if a resident did not receive sufficient counseling to cure, improve, or palliate the resident's behavioral health issue(s).

findings: 1. A review of R1's medical record revealed a treatment plan dated in 2024. The treatment plan stated: "...The services provided to resident are group sessions Monday, Tuesday, Wednesday, and Friday (minimum 20 hours weekly), parent contact (1x weekly), individual session (1x weekly)..." However, the treatment did not include the number of hours individual counseling was to be provided to R1. 2. A review of R2's medical record revealed a treatment plan dated in 2024. The treatment plan stated: "...The services provided to resident are group sessions Monday, Tuesday, Wednesday, and Friday (minimum 20 hours weekly), parent contact (1x weekly), individual session (1x weekly)..." However, the treatment did not include the number of hours individual counseling was to be provided to R1. 3. A review of R3's medical record revealed a treatment plan dated in 2024. The treatment plan stated: "...The services provided to resident are group sessions Monday, Tuesday, Wednesday, and Friday (minimum 20 hours weekly), parent contact (1x weekly), individual session (1x weekly)..." However, the treatment did not include the number of hours individual counseling was to be provided to R1. 4. A review of R4's medical record revealed a treatment plan dated in 2024. The treatment plan stated: "...The services provided to resident are group sessions Monday, Tuesday, Wednesday, and Friday (minimum 20 hours weekly), parent contact (1x weekly), individual session (1x weekly)..." However, the treatment did not include the number of hours individual counseling was to be provided to R1. 5. In a joint interview, E1 and E2 acknowledged R1's, R2's, R3's and R4's treatment plan did not include the frequency and number of hours individual counseling was to be provided to R1, R2, R3, and R4.

evidence: Based on record review and interview, the administrator failed to ensure assistance in the self-administration of medication provided to a resident was in compliance with an order and documented in the resident's medical record, for one of two 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 facility documentation revealed an incident report, dated November 20, 2024. The incident report stated "DESCRIPTION OF INCIDENT (Including events leading up to incident): On the morning of 11/19/2024 at approximately 12:45am [R1] reported that [R1] had taken 14-17 Acetaminophen on the evening of 11/15/2024. Personnel member [E8] asked how [R1] obtained Acetaminophen pills. Resident stated, " I told [E6] that I had a headache and needed some Tylenol. When I went in to the room to take the medicine I didn't have a drink and there weren't any in the fridge. [E6] went into the back room to get me a bottle of water and when [E6] did, I poured some of the pills in my hand when [E6] wasn't in the room with me. Then I took them later that night." Personnel asked [R1] why [R1] took the acetaminophen and [R1] reported that [R1] tried to kill [R1]. [R1] reported to Personnel that, that was [R1's] first ever suicide attempt and that [R1] had been struggling with suicidal ideation for the past two weeks. Personnel asked [R1] if [R1] was currently suicidal or had any intent to hurt [R1]. [R1] said [R1] was not suicidal and had no intent to harm [R1] and committed to Personnel that, although [R1] did not feel good, [R1] was stable and safe..." 2. A review of R1's medical record revealed a medication order for "Acetaminophen 500 mg by mouth every 6 hours as needed for fever or pain ..." dated November 5, 2024. 3. A review of R1's medical record revealed a medication administration record (MAR) for November, 2024. The MAR revealed R1 received "Acetaminophen 500 mg" on the following dates and times: -November 11, 2024 at 12:09 PM; -November 15, 2024 at 2:15 PM, 6:51 PM and 11:15 PM; and -November 16, 2024 at 11:27 PM. The MAR contained a section titled "Personnel signature and title" ; The section contained various staff initials on the aforementioned dates, however, the document did not contain E6 ' s signature or initials, and documentation of E6 providing assistance in the self-administration of medication to R1 for "Acetaminophen 500 mg", as indicated in the aforementioned incident report, was not available for review. 4. A review of R4's medical record revealed a medication order for "Citalopram 20 mg 1 tablet by mouth daily" dated October 29, 2024. 5. A review of R4's medical record revealed a medication administration record (MAR) for November, 2024. The MAR revealed R4 received "Citalopram 20 mg" on the following dates: -November 4-18, 2024 and November 20-22, 2024. However, documentation to indicate R4 received "Citalopram 20 mg" on November 19, 2024, was not available for review. 6. In a joint interview, E1 reviewed R1's MAR with the Compliance Officer, and acknowledged E6 did not document the assistance of self-administration of medication to R1. Additionally, E1 reported the pharmacy ran out of "Citalopram 20 mg" for R4, and R4 missed one dose of "Citalopram 20 mg" on November 19, 2024. E1 and E2 acknowledged assistance in the self-administration of medication was not provided to R1 and R4 in compliance with R1's and R4's medication orders, and assistance in the self-administration of medication was not documented in R1's medical record.

evidence: Based on observation, record review 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 a bathroom in R2's and R4's shared bedroom. The bathroom contained one grab bar mounted to a wall by the toilet area, and one grab bar mounted to the wall of the shower. 2. During the environmental inspection of the facility, the Compliance Officer observed a hallway bathroom. The bathroom contained one grab bar mounted to a wall in the shower. 3. During the environmental inspection of the facility, the Compliance Officer a bathroom in R3's bedroom. The bathroom contained one grab bar mounted to the wall of the shower. 4. A review of R2's medical record revealed a behavioral health assessment dated in 2024. The behavioral health assessment stated "History of suicide or homicide attempts?...Suicide attempt when 12 by cutting, stabbing self and didn't tell anyone. When 14, [R2] tried to hang self from a shower bar and gave up after it pulled down...Recent suicidal/homicidal ideation? Pt reported suicide attempt roughly 2 weeks ago to staff ..." 5. A review of R4's medical record revealed a behavioral health assessment dated in 2024. The behavioral health assessment stated "History of suicide or homicide attempts?...Resident reported 3 suicide attempts at ages 16-17. Resident reported trying to overdose ..." 6. In a joint interview, E1 and E2 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.


state: AZ

facility_name: STEP TWO RECOVERY CENTER

summary: Complaint - 6/28/2024

raw_content: An on-site investigation of complaint AZ00209394 was conducted on June 28, 2024 and no deficiencies were cited:

inspection_type: Complaint


summary: Complaint - 4/18/2024

raw_content: No deficiencies were found during the on-site plan investigation of complaint AZ00208622 conducted on April 18, 2024.


summary: Complaint;Compliance (Annual) - 3/21/2024

raw_content: On October 10, 2023, the Department issued a Notice of Intent to Revoke for license BH2607. The Licensee, Step Two Recovery Center, LLC and the Department entered into a Settlement Agreement to include any health care institution owned and/or operated by the licensee, with an execution date of January 10, 2024. On March 21, 2024, the Department conducted an on-site compliance inspection and complaint inspection for complaint AZ00201830 and found the licensee, Step Two Recovery Center LLC, to be out of compliance with the following terms included in the agreement: -Term #13. "Licensee agrees that "a personnel record is maintained for each personnel member"... pursuant to A.A.C. R9-10-706(G)-(H). -Term #17. "Licensee agrees to remain in substantial compliance with A.AC. Title 9, Chapter 10, Article 7." Per A.R.S. 36-401(46) "Substantial compliance" means that the nature or number of violations revealed by any type of inspection or investigation of a health care institution does not pose a direct risk to the life, health or safety of patients or residents. The licensee failed to meet the requirements of the Settlement Agreement for Term #17 as indicated by the three (3) repeat deficiencies and the three (3) new deficiencies cited in the compliance Statement of Deficiencies, Event ID: 88O511. The following deficiencies were found during the on-site compliance inspection and investigation of complaint AZ00201830 conducted on March 21, 2024:

inspection_type: Complaint;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 including initial training and continued competency training in fall prevention and fall recovery. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not developed and implemented.

findings: 1. A review of facility documentation revealed a training program for all staff regarding fall prevention and fall recovery was not available for review. 2. A review of E1's, E2's, E3's, E4's, E5's, E6's, E7's, E8's, and E10's personnel records revealed initial training in fall prevention. However, training fall recovery was not included. 3. In an interview, E1 and E2 acknowledged a fall prevention and fall recovery training program was not developed and the initial training for E1, E2, E3, E4, E5, E6, E7, E8, and E10 did not include fall recovery. This is a repeat deficiency from the on-site compliance and complaint inspection conducted on February 16, 2023.

rule: An administrator shall ensure that: 2. Documentation of current contracted services is maintained that includes a description of the contracted services provided.

evidence: Based on record review and interview, the administrator failed to ensure documentation of current contracted services included a description of the contracted services provided, for one registered nurse (RN).

findings: R9-10-101.56. "Contracted services" means medical services, nursing services, behavioral health services, health-related services, ancillary services, or environmental services provided according to a documented agreement between a health care institution and the person providing the medical services, nursing services, health-related services, ancillary services, or environmental services. 1. A review of E8's personnel record revealed E8 was hired as the RN. 2. A review of E8's personnel record revealed a contract between E8 and the facility (dated September 2, 2015). The contract stated "The contract remains in effect for one year from the date of signing." However, documentation of current contracted services including a description of the contracted services provided was not available for review. 3. In a joint interview, E1 and E2 acknowledged a current contract for E8 was not available for review.

rule: F. An administrator shall ensure that a personnel member, or an employee, a volunteer, or a student who has or is expected to have more than eight hours of direct interaction per week with residents, provides evidence of freedom from infectious tuberculosis: 1. On or before the date the individual begins providing services at or on behalf of the behavioral health residential facility, and 2. As specified in R9-10-113.

evidence: Based on record review and interview, the administrator failed to ensure personnel members provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113(A)(B), for four of ten personnel members sampled. The deficient practice posed a TB exposure risk to residents.

findings: R9-10-113(B)(1)(a)(i) A health care institution's chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specified in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: a. Documentation of a negative Mantoux skin test or other tuberculosis screening test that: i. Is recommended by the U.S. Centers for Disease Control and Prevention (CDC), A review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (pre-placement), two-step testing should be used." 1. A review of E3's (hired after February 16, 2023) personnel record revealed revealed documentation of a single negative TST, dated in April 2023. However, documentation of the second step of the recommended two-step TST was not available for review. 2. A review of E4's (hired after February 16, 2023) personnel record revealed revealed documentation of a single negative TST, dated in October 2023. However, documentation of the second step of the recommended two-step TST was not available for review. 3. A review of E5's (hired after February 16, 2023) personnel record revealed revealed documentation of a single negative TST, dated in December 2023. However, documentation of the second step of the recommended two-step TST was not available for review. 4. A review of E6's (hired after February 16, 2023) personnel record revealed revealed documentation of a single negative TST, dated in October 2023. However, documentation of the second step of the recommended two-step TST was not available for review. 6. In an interview, E2 reported to be unaware of the second step of the recommended two-step TST and would have E3, E4, E5, and E6 go get the second recommenced TST. 7. In an joint interview, E1 and E2 acknowledged documentation of evidence of freedom from infectious TB, as specified in Arizona Administrative Code (A.A.C.) R9-10-113(A)(B) was not available for review. This is a repeat deficiency from the on-site compliance and complaint inspection conducted on February 16, 2023.

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 was maintained for each personnel member to include documentation of compliance with the requirements in Arizona Revised Statutes (A.R.S) \'a7 36-411(C)(1)(2), for five of ten personnel records sampled. The deficient practice posed a risk if E2, E3, E4, E5, and E6 were a danger to a vulnerable population.

findings: A.R.S. \'a7 36-411(C)(1)(2) 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. 1. A review of E2's (hired after February 16, 2023) personnel record revealed documentation of compliance with A.R.S. \'a7 36-411(C)(1) was not available for review. 2. A review of E3's (hired after February 16, 2023) personnel record revealed documentation of compliance with A.R.S. \'a7 36-411(C)(1) was not available for review. 3. A review of E4's (hired after February 16, 2023) personnel record revealed documentation of compliance with A.R.S. \'a7 36-411(C)(1) was not available for review. 4. A review of E5's (hired after February 16, 2023) personnel record revealed documentation of a valid fingerprint clearance card. However, documentation of compliance with A.R.S. \'a7 36-411(C)(1)(2) was not available for review. 5. A review of E6's (hired after February 16, 2023) personnel record revealed documentation of compliance with A.R.S. \'a7 36-411(C)(1) was not available for review. 6. In an interview, E1 reported E1 contacts all references but does not document the information. 7. In a joint interview, E1 and E2 acknowledged E2's, E3's, E4's, E5's and E6's documentation of compliance with A.R.S. \'a7 36-411(C)(1)(2) was not available for review. This is a repeat deficiency from the on-site compliance and complaint inspection conducted on February 16, 2023.

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) as specified in R9-10-113(A)(2), for three of three residents sampled. The deficient practice posed a TB exposure risk to residents.

findings: R9-10-113.A.2.a.(i-iii) If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that: 2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, baseline screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1); 1. A review of R1's, R2's, and R3's (all admitted in 2024) medical records revealed baseline screenings were not available for review. 2. In a joint interview, E1 and E2 acknowledged the administrator failed to ensure R1, R2, and R3 provided evidence of freedom from infectious TB as specified in R9-10-113(A)(2).

rule: A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that: 4. Includes: b. The physical health services or behavioral health services to be provided to the resident;

evidence: Based on record review and interview, the administrator failed to ensure a treatment plan was developed for each resident to include the number of hours of counseling to be provided to the resident per R9-10-716(B)(2), for three of three residents sampled. The deficient practice posed a risk if a resident did not receive treatment to cure, improve, or palliate their behavioral health issue at the health care institution.

findings: 1. A review of R1's medical record revealed a treatment plan (dated in March 2024). The treatment plan did include the frequency of counseling to be provided to the resident. However, the treatment plan did not include the number of hours of counseling to be provided to R1. 2. A review of R2's medical record revealed a treatment plan (dated in February 2024). The treatment plan did include the frequency of counseling to be provided to the resident. However, the treatment plan did not include the number of hours of counseling to be provided to R2. 3. A review of R3's medical record revealed a treatment plan (dated in February 2024). The treatment plan did include the frequency of counseling to be provided to the resident. However, the treatment plan did not include the number of hours of counseling to be provided to R3. 4. In a joint interview, E1 and E2 acknowledged R1's, R2's, and R3's treatments plan did not include the number of hours of counseling to be provided to R1, R2, and R3.


facility_name: BACK TO LIFE, INC

summary: Compliance (Annual) - 1/15/2026

raw_content: The following deficiency was found during the on-site compliance inspection conducted on January 15, 2026.

inspection_type: Compliance (Annual)

rule: R9-10-711.A.2. Resident Rights A. An administrator shall ensure that: 2. At the time of admission, a resident or the resident's representative receives a written copy of the requirements in subsection (B) and the resident rights in subsection (E); and

evidence: Based on a record review, documentation review, and interview, the administrator failed to ensure at the time of admission, a resident received a written copy of the requirements in subsection (B) and the resident rights in subsection (E), for one of two resident records sampled. The deficient practice posed a risk if residents were unaware of the requirements and their rights.

findings: 1. A review of R2's medical record revealed no documentation to indicate R2 or the resident’s representative received a written copy of the resident rights. 2. A review of facility documentation revealed a policy and procedure titled "Resident Rights -English Version" dated March 6, 2006. The policy stated, “...The resident’s rights will be conspicuously posted on the premises in the common area (usually on the living room or dining room). At the time of admission, the resident or resident’s representative shall receive a written copy of this policy explaining the resident's rights…” 3. In an interview, E2 reported that a copy of the resident’s rights was emailed to the guardian of R2, but could not locate the email showing that the resident’s rights were received. 4. In an exit interview, the findings were reviewed with E1 and E2, and no additional comments, statements, or documentation were provided regarding the findings.


summary: Compliance (Annual) - 1/15/2025

raw_content: The following deficiency was found during the on-site compliance inspection conducted on January 15, 2025.

rule: C. An administrator shall ensure that a resident's medical record contains: 9. Orders;

evidence: Based on record review and interview, the administrator failed to ensure a resident's medical record contained orders for two of two resident records sampled. The deficient practice posed a risk as medication taken by residents could not be verified against a medication order.

findings: 1. A review of R1's medications and prescription labels revealed R1 received assistance in the self administration of the following medications: - Guanfacine HCL 4 MG Tablet, Take 1 tablet by mouth every morning; - Fluoxetine HCL 20 MG Capsule, Take 1 capsule by mouth every morning; - Cyproheptadine 4 MG Tablet, Take 1 tablet by mouth twice a day; - Bisacodyl USP 5 MG Tablets; - Haloperidol 1 MG Tablet, Take 1 tablet by mouth twice daily; - Hydroxyzine PAM 25 MG Cap, Take 1 capsule by mouth twice daily; and - Melatonin 5 MG Tablets. 2. A review of R1's medical record revealed medication orders for the aforementioned medications were not available for review. 3. A review of R1's medications and prescription labels revealed the phrase "twice a day" from the prescription label for R1's medication "Cyproheptadine 4 MG Tablet" had been scribbled out with black marker. The word "AM" was written on the bottom of the prescription label. A review of R1's medication administration record (MAR) revealed R1 received assistance in the self administration of "Cyproheptadine 4 MG Tablet" once daily at 7:00 AM for fifteen days. However, an order to change medication dosage was not available for review in R1's medical record. 4. A review of R2's medications and prescription labels revealed R2 received assistance in the self administration of the following medications: - Amphetamine Salts 5 MG Tablets, Take one tab by mouth every morning; - Adderall 5 MG; - Polyethylene Glycol 3350 POWD, Mix 1 capful w/ 8 ox of water every day for 30 days; and - Hydroxyzine PAM 50 MG Cap, Take 1 capsule by mouth twice a day at 7:00 am and 7:00 pm as needed for anxiety. 5. A review of R2's medical record revealed medication orders for the aforementioned medications were not available for review. 6. A review of R2's medications and prescription labels revealed the phrase "mouth two times a day at 7:00 am and" from the prescription label for R2's medication "Hydroxyzine PAM 50 MG Cap" had been scribbled out with black marker. The words "PM only" were written on the bottom of the prescription label. A review of R2's MAR revealed R2 received assistance in the self administration of "Hydroxyzine PAM 50 MG Cap" once daily at 6:00 PM for five days. However, an order to change medication dosage was not available for review in R2's medical record. 7. In an exit interview, E1 and E2 reported the facility was having trouble obtaining medication orders from the residents' prescriber's, as the providers claimed giving the facility medications orders was a HIPAA violation.


summary: Complaint - 8/1/2024

raw_content: An on-site investigation of complaint AZ00213476 was conducted on August 1, 2024 and no deficiencies were cited:


summary: Complaint;Compliance (Annual) - 1/24/2024

raw_content: The following deficiencies were found during the on-site compliance inspection and investigation of complaint AZ00198388 conducted on January 24, 2024:

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

evidence: Based on documentation review, record review and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of the individual's completed in-service education as required by policies and procedures, for two of seven personnel members sampled.

findings: R9-10-101.115. "In-service education" means organized instruction or information that is related to physical health services or behavioral health services and that is provided to a medical staff member, personnel member, employee, or volunteer. 1. A review of facility documentation revealed a policy and procedure titled "Fall Prevention and Fall Recovery" (dated March 28, 2023). The policy and procedure stated " ...All staff employed with Back to Life, Inc. who provide direct care services [sic] ...will be required to complete mandatory training program initially, and continued competency annually ..." 2. A review of E4's (hired in 2019) personnel record revealed documentation of fall prevention and fall recovery training, dated January 11, 2023. However, documentation of annual fall prevention and fall recovery training was not available for review. 3. A review of E5's (hired in 2018) personnel record revealed documentation of fall prevention and fall recovery training, dated August 14, 2022. However, documentation of annual fall prevention and fall recovery training was not available for review. 4. In a joint interview, E1 and E2 acknowledged E4's and E5's personnel records did not include documentation of the individual's completed in-service education as required by policies and procedures. This is a repeat deficiency from the on-site compliance inspection conducted on December 28, 2022.

evidence: Based on record review, documentation review, and interview, the administrator failed to ensure a personnel record included documentation of compliance with requirements in Arizona Revised Statutes (A.R.S.) \'a7 36-411, for one of seven personnel members sampled. The deficient practice posed a risk if E3 was a danger to a vulnerable population.

findings: 1. A review of E3's personnel record revealed documentation of compliance with A.R.S. \'a7 36-411(A). 2. A review of the Department of Public Safety (DPS) Fingerprint Clearance verification website revealed E3's status as "Invalid." 3. A review of facility documentation revealed documentation of compliance with A.R.S. \'a7 36-411(C)(2), dated in October 2023. 4. In an interview, E2 attempted to contact E3 via telephone call and left a voicemail. However, E3 did not contact E2 while the Compliance Officer was on-site. 5. A review of facility documentation revealed daily staffing schedules, dated from October 2023 to January 2024. A review of the daily staffing schedules revealed E3 never worked alone. 6. In a joint interview, E1 and E2 acknowledged E3's card became invalid while employed at BH2772, and acknowledged documentation of a valid fingerprint clearance card and A.R.S. \'a7 36-411(C)(2) was not available for review.


facility_name: INTERMOUNTAIN CENTERS FOR HUMAN DEVELOPMENT

summary: Complaint - 3/3/2026

raw_content: No deficiencies were found during the on-site  investigation of complaint 00158730, 00157687, and 00156798 conducted on March 3, 2026:


summary: Complaint;Compliance (Annual) - 12/23/2025

raw_content: The following deficiencies were found during the on-site compliance inspection and investigation of complaints 00154067, 00153767, 00150068, and 00147647 conducted on December 23, 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 and interview, the administrator failed to ensure a resident admitted with limited ability to function independently to a behavioral health residential facility, licensed to provide behavioral health services to individuals whose behavioral health issue limits the individuals' ability to function independently, received continuous protective oversight. The deficient practice posed a risk as a minor did not receive continuous protective oversight while admitted to a behavioral health residential facility.

findings: 1. A review of documentation revealed an incident report dated December 2025. The incident report stated, “DESCRIPTION OF THE INCIDENT…At around 9:58 PM R2 decided to AWOL and exit the home. E8 attempted to communicate with the [R2], but the [R2] did not reciprocate and continued to leave the home. On-call was contacted immediately and notified at 9:58 PM. 911 was called at 10:00 PM. [R2] guardian was contacted at 10:15 PM. R2 returned to site at around 12:27 Am 12/19/2025. R2 was informed that they could not go to their rooms and would need to be visual searched by emptying their pocket. R2 complied to search but refused to stay out of their room. R2 shared that they had self-harmed while they were gone with a piece of glass they found while away from the home. R2 complained of having similar symptoms to having low blood sugar. R2 was given water and some gummy fruit snacks to help improved condition. R2 began to be less communicative and complained of having blurry vision. At around 12:27 AM, on-call was contacted and updated of the [R2] condition and advised calling 911. 911 was called at 12:28 AM. Paramedics arrived and examined the [R2] and transported the [R2] to TMC hospital to be medically cleared. As of writing [R2] still continues to be held at the hospital for medical clearance. Guardian was contacted and updated at 6:10 AM.” 2. A review of the facility's policies and procedures revealed a policy titled, "Missing Person from a Residential Facility." The policy stated, "When a member is missing from a residential facility, the following actions should be taken by personnel: G. Personnel will attempt to locate the member in the general vicinity and at all locations where the member is known to frequent..." 3. In an interview with E1, E1 reported E8 was the only staff on-site when R2 walked out the facility door, and E8 did not leave the facility. E1 also reported R2 was discharged from the facility due to being recommended for a higher level of care. 4. In a joint exit interview, the findings were reviewed with E1, E2, E3, E4, and E5, and no additional comments, statements, or documentation were provided regarding the findings.

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 documentation review, record review, and interview, the administrator failed to ensure assistance in the self-administration of medication provided to a resident was in compliance with an order, for one of four 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 documentation revealed an incident report dated October 2025. The incident report stated, “DESCRIPTION OF THE INCIDENT…R1 has a night med of DIVALPROEX 500MG. That was not in Netsmart to administer, due to R1 medication not assigned on list. Guardian was called at 8:10PM.” 2. A review of R1’s medical record revealed a medication order for Divalproex. The medication order stated, “Give instructions: 500 Milligram = 1 Tablet At Bedtime.” 3. A review of R1’s medical record revealed a Medication Administration Record (MAR) dated September and October 2025. The MAR revealed R1 missed the Divalproex medication on October 1, 2025. 4. In a joint interview with E1, E2, E3, E4, and E5, E1 and E2 reported the electronic Medication Administration Record (eMAR) was not syncing to R1’s medication order for Divalproex on October 1, 2025. E2 reported all staff are encouraged to rely on the eMAR. E1 and E2 reported they were unsure why the medication order did not show up on the eMAR. 5. In a joint exit interview, the findings were reviewed with E1, E2, E3, E4, and E5 and no additional comments, statements, or documentation were provided regarding the findings.


summary: Complaint - 7/23/2025

raw_content: The following deficiencies were found during the on-site investigation of complaint AZ00137040 conducted on July 23, 2025:

rule: R9-10-113.A.1-2. Tuberculosis Screening A. If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that: 1. Are consistent with recommendations in Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019, published by the U.S. Department of Health and Human Services, Atlanta, GA 30333, available at https://www.cdc.gov/mmwr/volumes/68/wr/mm6819a3.htm, incorporated by reference, on file with the Department, and including no future editions or amendments; and 2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1); b. If an individual may have a latent tuberculosis infection, as defined in A.A.C. R9-6-1201: i. Referring the individual for assessment or treatment; and ii. Annually obtaining documentation of the individual's freedom from symptoms of infectious tuberculosis, signed by a medical practitioner, occupation health provider, as defined in A.A.C. R9-6-801, or local health agency, as defined in A.A.C. R9-6-101; c. Annually providing training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed by or providing volunteer services for the health care institution; d. Annually assessing the health care institution's risk of exposure to infectious tuberculosis; e. Reporting, as specified in A.A.C. R9-6-202, an individual who is suspected of exposure to infectious tuberculosis; and f. If an exposure to infectious tuberculosis occurs in the health care institution, coordinating and sharing information with the local health agency, as defined in A.A.C. R9-6-101, for identifying, locating, and investigating contacts, as defined in A.A.C. R9-6-101.

evidence: Based on record review and interview, the chief administrative officer failed to annually provide training and education related to recognizing the signs and symptoms of tuberculosis (TB) to individuals employed by or providing services for the health care institution. The deficient practice posed a risk to the health and safety of residents.

findings: 1. A review of E5's personnel record revealed TB signs and symptoms training dated July 17, 2024. However, documentation of current TB signs and symptoms training was not provided for review. 2. In an exit interview, E1 and E2 reviewed the findings and reported the required training will be completed and placed in the personnel records.

rule: R9-10-706.G.3.c. Personnel G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes: 3. Documentation of: c. The individual's completed orientation and in-service education as required by policies and procedures;

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel member that included documentation of the individual's in-service education as required by policies and procedures. The deficient practice posed a risk if personnel were not receiving the required training per the facility's own policy and procedures.

findings: 1. A review of facility documentation revealed a policy titled, "Permissible Behavior Management Techniques." The policy stated, "... 3. 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 preventive interpretations 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; 4. Only when the above techniques have been proven to be ineffective, should staff utilize some form of emergency safety response. Staff should use the least amount of intervention to safely manage the individual's "out-of-control" behavior; 5. The emergency safety responses utilized should be only those taught in the approved curriculum Crisis Prevention Intervention (CPI), Safety Care or Prevention and Support (Specific to programs supporting members supported by the Arizona Department of Economic/Division of Developmental Disabilities)..." 2. A review of E5's, E6's, and E7's personnel records revealed no documentation of training in Crisis Prevention intervention (CPI). 3. In an exit interview, E1 and E2 reviewed the findings and reported that language regarding crisis prevention intervention will be updated.

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 was reviewed and updated on an on-going basis according to the review date specified on the treatment plan. The deficient practice posed a risk to the health and safety of residents.

findings: 1. A review of R1's medical record revealed a treatment plan dated July 9, 2025. However, the plan did not document a specified review date. 2. In an exit interview, E1 and E2 reviewed the findings and reported treatment plans will be updated to include a specified review date.


summary: Complaint - 7/16/2025

raw_content: An on-site investigation of complaint 00136440 was conducted on July 16, 2025, and the following deficiency was cited:

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 use or have access to any materials, furnishings, or equipment or participate in any activity or treatment which may have presented a threat to the resident's health or safety based on the resident's documented diagnosis, treatment needs, developmental levels, social skills, verbal skills, or personal history.

findings: 1. A review of R1's medical record revealed R1 had a documented history of self-harm. 2. A review of R1's medical record revealed an incident report dated July 2025. The incident stated "[R1] approached BHT [E8] at about 1945 to report that [R1] had a slip up with self-harm. BHT [E8] asked [R1] where [R1] had self-harmed and what with. [R1] said it was [R1's] left arm and that [R1] had what [R1] had self-harmed with was in [R1's] pocket. [R1] gave it to BHT [E8] when asked for it. It was a screw washer. BHT [E8] asked to see [R1's] left arm; [R1] refused. [E8] said [E8] would give [R1] a moment, but that would ultimately have to see [R1's] left arm in order to ensure [R1] was not in need of medical attention. Site Supervisor informed at 2022. Guardian informed at 2020. When [R1] showed [E8] [R1's] arm, there were several superficial cuts on both sides of the left arm. They looked a lot like road rash. On-call RN advised Angel House staff to transport [R1] to ED for medical clearance. A thorough safety search was done in [R1's] bedroom. BHT [E8] found three more screw washers and a thin piece of metal with a sharp edge on the shelf in the closet. A wooden BBQ skewer was found on the head of the door, and [R1] confessed to having a bent piece of metal as well as a piece of broken eyeglasses hidden beneath [R1's] bed. [R1] told BHT [R1] had hidden the last two of these items inside of [R1's] giant stuffed animal. The giant stuffed animal was checked for safety during inventory before it was given to [R1]. After the safety search, the stuffed animal was confiscated. All sharps were removed from the bedroom, including furnishings that had sharp objects [R1] could potentially be used to self-harm. [R1] was taken to emergency department]. After being triaged, [R1] was informed by an RN that [R1] would need a psychiatric evaluation, labs, urinalysis, and an EKG to be medically cleared to return to Angel House...." 3. In an interview, R1 reported R1 found the identified screws in R1's bedroom. R1 reported R1 felt R1 could use any object to self-harm. R1 reported R1 felt safe at the facility and denied any current suicidal ideation or plans. 4. In an interview, E1 and E2 reported R1 and R1's belongings were thoroughly searched at admission. E1 and E2 acknowledged R1 had a history of self-harm and gained access to materials that R1 utilized to self-harm, requiring medical attention.


summary: Compliance (Annual) - 10/1/2024

raw_content: No deficiencies were found during the on-site compliance inspection conducted on October 1, 2024.


summary: Change of Service - 7/22/2024 - 7/25/2024

raw_content: An off-site review of documentation to modify the population from adults to children was completed on July 25, 2024.

inspection_type: Change of Service


summary: Change of Service - 11/16/2023 - 11/20/2023

raw_content: No deficiencies were found during the off-site inspection to modify the facility license from children to adults completed on November 20, 2023.


summary: Compliance (Annual) - 9/12/2023

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on September 12, 2023:

rule: C. If a behavioral health residential facility provides assistance in the self-administration of medication, an administrator shall ensure that: 2. The following assistance is provided to a resident: d. Verifying that the medication is taken as prescribed by the resident's medical practitioner by confirming that: ii. The resident is taking the dosage of the medication stated on the medication container label or according to an order from a medical practitioner dated later than the date on the medication container label, and

evidence: Based on record review and interview, the administrator failed to ensure a resident provided assistance in the self-administration of medication was taking the dosage of the medication according to an order from a medical practitioner. 1. A review of R1's medical record revealed an order from a medical practitioner, dated April 5, 2023, for "lithium carbonate ER 450 mg tablet, extended release take 1 tablet by oral route 2 times every day." Further review revealed R1's medication administration record (MAR) which revealed R1 received assistance in the self-administration of "Lithium 450 mg ERT tablet," during the month of April, 2023. However, the MAR indicated R1 was administered one Lithium 450 mg tablet per day from April 6, 2023 through April 23, 2023. 2. In an interview, E1 acknowledged a failure to ensure R1 was taking the dosage medication as ordered.

rule: E. When medication is stored at a behavioral health residential facility, an administrator shall ensure that: 3. Policies and procedures are established, documented, and implemented for: a. Receiving, storing, inventorying, tracking, dispensing, and discarding medication, including expired medication;

evidence: Based on observation, documentation review and interview, the administrator failed to ensure policies and procedures were implemented for discarding medication.

findings: 1. During a tour of the facility the Compliance Officer observed a metal locker used for storing medications. Inside the locker was a blister packet of "Acetaminophen 500MG Tab" prescribed to R1 (discharged in 2023). 2. A review of facility policy and procedures revealed a policy titled, "Medication Inventory, Storage & Disposal," (dated May 8, 2023). The policy indicated medications were to be disposed of after, "The member is no longer in treatment..." 3. In an interview, E1 reported the medication should not be in the facility as R1 had discharged months prior. E1 acknowledged the medication had not been disposed of according to policy and procedure.


facility_name: ALL ABOUT KIDS

summary: Complaint - 12/31/2025

raw_content: The following deficiencies were found during the on-site  investigation of complaint 00154603 conducted on December 31, 2025.

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

evidence: Based on record review and interview, the administrator failed to ensure documentation of current contracted services was maintained to include a description of the contracted services provided. The deficient practice posed a risk as the administrator did not maintain a current contract for a registered nurse (RN) who was providing services on behalf of the behavioral health residential facility, and the repeated violation shows a pattern of non-compliance to ensure the health and safety of residents.

findings: 1. A review of E4’s personnel record revealed E4 served as the facility's contracted RN. 2. A review of E4's personnel record revealed a document titled "Contractor Agreement," which stated, "This Agreement is made between All About Kids... and [E4]... this contract will be ongoing as long as services is provided... Contractor shall provide the following RN services monthly to All About Kids... Training staff members in assistance in the self-administration of medication... Review Medication storage monthly... Review Medication Administration Records monthly... Review Medication policy and procedures annually..." No evidence demonstrated compliance with R9-10-706.K.5, and the signature lines and dates at the bottom of the contract remained blank. 3. In an interview, E1 acknowledged no contract was maintained to include a description of the contracted services provided by E4. 4. In an exit interview, the findings were discussed with E1, and no additional comments or documentation were provided. This is a repeated violation from the on-site compliance inspection conducted on December 27, 2022,

rule: R9-10-707.A.13.b. Admission; Assessment A. An administrator shall ensure that: 13. Except as provided in subsection (E)(1)(d), a resident provides evidence of freedom from infectious tuberculosis: b. As specified in R9-10-113.

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for two of three resident records sampled. The deficient practice posed a TB exposure risk to residents, and the repeated violation shows a pattern on non-compliance to ensure the health and safety of residents.

findings: R9-10-113.A.2.a.(i-iii) If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that: 2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, baseline screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1); 1. A review of R1’s medical record revealed documentation of a TB screening and risk assessment conducted more than two (2) months after R1’s admission, which did not comply with R9-10-707.A.13.b. 2. A review of R2's medical record revealed no evidence of a TB screening and risk assessment. 3. In an exit interview, the findings were discussed with E1, and no additional statements or documentation were provided. This is a repeated violation from the on-site compliance inspection conducted on August 7, 2024.

rule: R9-10-708.A.4.c. Treatment Plan A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that: 4. Includes: c. The signature of the resident or the resident's representative, and date signed, or documentation of the refusal to sign;

evidence: Based on record review and interview, the administrator failed to ensure a treatment plan was developed and implemented for each resident which included the signature of the resident or the resident's representative, and date signed, or documentation of the refusal to sign, for one of two resident records sampled. The deficient practice posed a risk if a treatment plan was not developed to articulate decisions and agreements before treatment was initiated, and the repeated violation shows a pattern of non-compliance to ensure the health and safety of residents.

findings: 1. A review of R1’s medical record revealed a treatment plan, dated in November 2025; however, no evidence existed of R1’s signature or R1’s representative’s signature, dates signed, or documentation of refusal to sign. 2. In an exit interview, the findings were discussed with E1, and no additional statements or documentation were provided. This is a repeated violation from the on-site investigation of complaints conducted on January 21, 2025.

rule: R9-10-708.A.5. Treatment Plan A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that: 5. If the treatment plan was completed by a behavioral health technician, is reviewed and signed by a behavioral health professional within 24 hours after the completion of the treatment plan to ensure that the treatment plan is complete and accurate and meets the resident's treatment needs; and

evidence: Based on record review, documentation review, and interview, the administrator failed to ensure a treatment plan completed by a behavioral health technician (BHT) was reviewed and signed by a behavioral health professional (BHP) within 24 hours after the completion of the treatment plan to ensure the treatment plan was complete and accurate and met the resident's treatment needs, for one of three resident records sampled. The deficient practice posed a risk as a treatment plan was not completed to articulate decisions and agreements of services to be provided.

findings: 1. A review of R2’s medical record revealed a treatment plan completed by a BHT; however, there was no documentation a BHP reviewed and signed the treatment plan within 24 hours of its completion. 2. In an exit interview, the findings were discussed with E1, and no additional statements or documentation were provided.

rule: R9-10-708.B.1. Treatment Plan B. An administrator shall ensure that: 1. A request for participation in developing a resident's treatment plan is made to the resident or the resident's representative,

evidence: Based on record review, documentation review, and interview, the administrator failed to ensure a request for participation in developing a resident's treatment plan was made to the resident or the resident's representative, for one of two resident records sampled. The deficient practice posed a risk as a treatment plan was not developed to articulate decisions and agreements before treatment was initiated.

findings: 1. A review of R1's medical record revealed documentation which indicated R1 was under legal guardianship, with the guardian acting as R1's representative. 2. A review of R1's medical record revealed an updated treatment plan; however, there was no evidence of a request for participation in developing R1's treatment plan made to R1's or R1's representative. 3. A review of facility documentation revealed a policy titled "Treatment services planning [sic] & Client Service Plans" (dated on September 18, 2023). The procedure stated, "...The plan shall be developed and implemented within seven days of admission and finalized within 30 days for all shelter home... The client's consent for a course of treatment specified in the treatment plan or updates shall be verified by dated signature of the client, and if applicable the clients parent guardian or designated representative [sic]..." 4. In an exit interview, the findings were discussed with E1, and no additional statements or documentation were provided.

rule: R9-10-708.B.2. Treatment Plan B. An administrator shall ensure that: 2. An opportunity for participation in developing the resident's treatment plan is provided to the resident or the resident's representative, and

evidence: Based on record review, documentation review, and interview, the administrator failed to ensure an opportunity for participation in developing a resident's treatment plan was provided to the resident or the resident's representative, for one of three resident records sampled. The deficient practice posed a risk as a treatment plan was not developed to articulate decisions and agreements before treatment was initiated.

findings: 1. A review of R1's medical record revealed documentation which indicated R1 was under legal guardianship, with the guardian acting as R1's representative. 2. A review of R1's medical record revealed an updated treatment plan; however, there was no documented evidence of an opportunity for participation in developing the treatment plan provided to R1 or R1's representative. 3. A review of facility documentation revealed a policy titled "Treatment services planning [sic] & Client Service Plans" (dated on September 18, 2023). The procedure stated, "...The plan shall be developed and implemented within seven days of admission and finalized within 30 days for all shelter home... The client's consent for a course of treatment specified in the treatment plan or updates shall be verified by dated signature of the client, and if applicable the clients parent guardian or designated representative [sic]..." 4. In an exit interview, the findings were discussed with E1, and no additional statements or documentation were provided.

evidence: Based on documentation 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. The deficient practice posed a risk as a minor child was not supervised by the facility personnel at all times, 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 "Behavioral health residential facility's scope of service [sic]" (dated on September 18, 2023). The procedure stated, "24-hour behavioral health supervision... Provide treatment to an individual experiencing a behavioral health issue that limits the individual's ability to be independent or causes the individual to require treatment to maintain or enhance independence... Provide children 10-17 a safe, nurturing, and positive environment that provides therapeutic care in a supportive home atmosphere, while promoting personal growth, development, and a change in 24 hours a day residential behavioral health facility [sic]..." 2. A review of facility documentation revealed a policy titled "Behavioral Health Services" (dated on September 18, 2023). The procedure stated, "Agency administrator shall ensure that... Continuous protective oversight; health services to maintain or enhance the resident's ability to function independently... Receives behavioral health services... Is provided an opportunity to participate in activities designed to maintain or enhance the resident's ability to function independently while... The resident receives services to maintain the resident's health, safety, or personal hygiene...: 3. A review of facility documentation revealed a document titled "AWOL Log Report," dated in May 2025, which stated, "Date: 5/23/25... Time: 8:30 pm... Criteria for Determining when a resident's absence is unauthorized: Resident is not within staff supervision and not able to be located. Staff members will check the following areas for the client: Kitchen, Bedrooms, Bathrooms, Garage, Front Yard and Backyard and the resident is no place to located [sic]. Within 5-10 minutes of checking the above areas staff members need to proceed to contact police to report resident is not able to be located, contact administrator to inform them of unauthorized absence... Resident Name: [R5]... Date & Time returned: Did not return... Incident that occurred: On the above date and time, staff were in the process of preparing dinner for the clients. At this time, all clients, including [R5], were seated in the living room watching a movie. Once dinner was ready, clients were called in to the dining area to eat. After dinner, clients were instructed to begin their evening hygiene routines and take showers. It was [R5's] turn to shower. [R5] initially went into [R5's] room to gather [R5's] clothes, then proceeded to the laundry room to wash some items. Shortly after, staff called [R5] into the office to administer [R5's] medication. [R5] complied and then proceeded to the bathroom to shower. While the rest of the clients remained in the living room watching a movie, staff, after some time, noticed the sound of the shower had stopped and went to check on [R5]. [R5] was seen in [R5's] bedroom, appearing to get ready for bed. Staff left [R5's] room momentarily and returned to the common area. A few minutes later, staff re-entered [R5's] room to follow up and discovered that the bedroom window was open. All of [R5's] belongings and clothing were missing. It became clear that [R5] had jumped put the window and left the premises without permission. Immediate checks of the front and back yards, as well as throughout the house, were conducted, but [R5] was not located. At that point, the police were notified, and a report was made to the DCS (Department of Child Services) Hotline, categorizing [R5] as a runaway... During the Incident: No distress or agitation was observed prior to [R5's] departure. [R5's] departure was not witnessed, but the method suggests premeditation and intent to leave undetected. After the Incident: [R5's] condition post-departure is unknown. No injuries were observed before [R5] left, and there were no signs of struggle or distress in [R5's] room..." No documentation was found provided which indicated R5 was located following the incident. 4. A review of facility documentation revealed a document titled "AWOL Log Report," dated in September 2025, which stated, "Date:09/30/2025... Time: 7:15pm... Criteria for Determining when a resident's absence is unauthorized: Resident is not within staff supervision and not able to be located. Staff members will check the following areas for the client: Kitchen, Bedrooms, Bathrooms, Garage, Front Yard and Backyard and the resident is no place to located [sic]. Within 5-10 minutes of checking the above areas staff members need to proceed to contact police to report resident is not able to be located, contact administrator to inform them of unauthorized absence... Resident Name: [R4]... Date & Time returned: N/A... Incident that occurred: On 09/30/2025 at approximately 7:15 PM, staff observed resident [R4] antagonizing another client within the Chandler House. [R4] began making comments that visibly upset the peer and then escalated to making sexual inappropriate remarks, which further aggravated the situation. The peer attempted to remove [R9] by going to [R9's] room, but [R4] continued mocking [R9] and asked staff to use the phone while laughing and imitating the peer's previous statements. Shortly thereafter, the peer struck [R4] on the arm, at which point staff intervened and redirected the peer to remain in [R9's] room for safety. [R4] observed the peer on headphones, then told staff [R4] was going outside to calm down. While again requesting phone access, staff informed [R4] that [R4's] comments would be documented. [R4] became verbally hostile and responded with profanity, stating [R4] would go to the neighbor's house to call the police. [R4] then exited the residence without permission and threated staff... Staff immediately contacted the non-emergency police line to report [R4] as AWOL. Approximately six minutes later, [R4] returned to the residence accompanied by the administrator. Upon re-entering, [R4] continued escalating by yelling profanity, racial slurs, an derogatory comments towards staff. Staff directed all other clients to remain in their rooms for safety while continuing attempts at verbal redirection with [R4]. Despite multiple prompts, [R4] stated, "I can call you whatever I want," and continued using aggressive and hostile language. While speaking on the phone with family members, [R4] made further direct threats towards staff, saying [R4] would... [R4] escalated further by approaching staff aggressively while striking [R4's self], smacking [R4's] own body, and punching [R4's own] arm. Staff reminded [R4] to maintain appropriate space and attempted additional verbal redirection. [R4] then attempted to throw the phone at staff, narrowly missing, and struck a window several times with [R4's] fist. [R4] then left the residence once more, running away from the home and placing [R4] AWOL for the second time..." No documentation was found or provided which indicated R4 was located following the incident. 5. In an exit interview, the findings were discussed with E1, and no additional statements or documentation were provided. This is a repeated violation from the on-site compliance inspection and investigation of complaints conducted on August 3, 2023.

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, documentation review, and interview, the administrator failed to ensure counseling was provided according to the number of hours identified in a resident's treatment plan, for two of three resident records sampled. The deficient practice posed a risk as a treatment plan was not completed to articulate decisions and agreements of services to be provided, and the repeated violation shows a pattern of non-compliance to ensure the health and safety of residents.

findings: 1. A review of R1's medical record revealed an initial treatment plan which stated, "Decrease aggression... Individual therapy using CBT and DBT... Psycho-educational groups on emotion regulation... Individual 1-2x weekly... Groups 2-3x weekly... Increase compliance with rules... Daily staff support... Weekly groups... Support ADHD management... Psychoeducation about ADHD... Weekly groups... Address trauma history... Individual therapy with trauma-informed CBT... 1x weekly individual therapy... Improve family relationships... Family therapy sessions... Monthly family therapy..." However, R1's initial treatment plan did not specifically identify the number of hours of counseling to be provided. 2. A review of R1's medical record revealed an updated treatment plan which stated, "Decrease aggression... Individual therapy using CBT and DBT... Psycho-educational groups on emotion regulation... Individual 1-2x weekly... Groups 2-3x weekly... Increase compliance with rules... Daily staff support... Weekly groups... Support ADHD management... Psychoeducation about ADHD... Weekly groups... Address trauma history... Individual therapy with trauma-informed CBT... 1x weekly individual therapy... Improve family relationships... Family therapy sessions... Monthly family therapy..." However, R1's updated treatment plan did not specifically identify the number of hours of counseling to be provided. 3. A review of R2's medical record revealed an initial treatment plan which stated, "Upon entrance into All About Kids Group Home a resident will attain/accomplish the following objectives... Have a complete physical examination... Enroll in school... Obtain clothing if needed... Review rules, regulations... Take part in an orientation period which outline all rules... Be introduced to all staff members and fellow residents... Take part in an Initial Assessment... Actively take part in creation of an Individualized Treatment Plan..." However, R2's initial treatment plan did not specifically identify the number of hours of counseling to be provided. 4. A review of R2's medical record revealed an updated treatment plan which stated, "Defiance, aggression... Psycho-education groups on emotion regulation... Individual CBT/DBT sessions... Poor impulse control... DBT distress tolerance and grounding... Substance use... Substance use education groups... Depressive symptoms... CBT-based individual therapy... Mood tracking and psychiatry sessions..." However, R2's updated treatment plan did not specifically identify the number of hours of counseling to be provided. 5. A review of facility documentation revealed a policy and procedure (dated on September 18, 2023), which stated, "An administrator shall ensure that counseling is... Provided according to the frequency and number of hours identified in the resident's treatment plan..." 6. In an exit interview, the findings were discussed with E1, and no additional statements or documentation were provided. This is a repeated violation from the on-site compliance inspection and investigation of complaints conducted on August 3, 2023

rule: R9-10-722.B.8.e. Physical Plant Standards B. An administrator shall ensure that: 8. A resident bedroom complies with the following: e. Has window or door covers that provide resident privacy;

evidence: Based on observation, record review, documentation review, and interview, the administrator failed to ensure a resident bedroom had a door cover which provided resident privacy. The deficient practice placed a resident at risk for violation of the right to privacy.

findings: 1. The Compliance Officer observed a resident bedroom without a door or alternative privacy covering. R3 was seated in the bedroom wrapped in a towel following a shower. 2. The Compliance Officer observed the damaged bedroom door with impact marks stored in the facility garage. 3. In an interview, E1 reported R3 damaged the bedroom door during a behavioral incident occurring between December 29 and December 30, 2025. 4. A review of facility documentation revealed an electronic incident report dated December 29, 2025, at 06:45 PM, describing R3 engaging in verbal aggression toward a peer during a recreational activity, escalating agitation following staff redirection, property destruction within the residence, damage to the bedroom door, and law enforcement involvement due to ongoing safety concerns. The report documented continued behavioral interventions and monitoring following de-escalation. 5. In an exit interview, the findings were discussed with E1, and no additional statements or documentation were provided.


summary: Complaint - 9/15/2025

raw_content: The following deficiencies were found during the on-site investigation of complaint 00144742 conducted on September 15, 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, record review, and interview, the administrator failed to ensure all staff received initial and continued competency training in fall prevention and fall recovery. The deficient practice posed a risk to the health and safety of residents if they were unable to be safely assisted during a fall.

findings: 1. A review of facility documentation revealed a policy titled, "Fall Prevention and Fall Recovery Training." The policy stated, "... Ongoing Training: Employees will receive initial training during orientation and ongoing competency training once a year..." 2. A review of E1's personnel record revealed a fall prevention training dated December 30, 2024, and fall recovery training dated September 25, 2023. However, documentation of current fall recovery training was not available for review. 3. A review of E2's personnel record revealed a fall prevention training dated December 30, 2024, and fall recovery training dated September 25, 2023. However, documentation of current fall recovery training was not available for review. 4. A review of E3's personnel record revealed a fall prevention and fall recovery training dated August 20, 2024. However, documentation of current fall prevention and fall recovery training was not available for review. 5. In an interview, E1 reviewed the findings and no additional documentation was provided for review.

rule: R9-10-113.A.1-2. Tuberculosis Screening A. If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that: 1. Are consistent with recommendations in Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019, published by the U.S. Department of Health and Human Services, Atlanta, GA 30333, available at https://www.cdc.gov/mmwr/volumes/68/wr/mm6819a3.htm, incorporated by reference, on file with the Department, and including no future editions or amendments; and 2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1); b. If an individual may have a latent tuberculosis infection, as defined in A.A.C. R9-6-1201: i. Referring the individual for assessment or treatment; and ii. Annually obtaining documentation of the individual's freedom from symptoms of infectious tuberculosis, signed by a medical practitioner, occupational health provider, as defined in A.A.C. R9-6-801, or local health agency, as defined in A.A.C. R9-6-101; c. Annually providing training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed by or providing volunteer services for the health care institution; d. Annually assessing the health care institution's risk of exposure to infectious tuberculosis; e. Reporting, as specified in A.A.C. R9-6-202, an individual who is suspected of exposure to infectious tuberculosis; and f. If an exposure to infectious tuberculosis occurs in the health care institution, coordinating and sharing information with the local health agency, as defined in A.A.C. R9-6-101, for identifying, locating, and investigating contacts, as defined in A.A.C. R9-6-101.

evidence: Based on record review and interview, the administrator failed to annually provide training and education related to recognizing the signs and symptoms of tuberculosis (TB) to individuals employed by or providing volunteer services for the health care institution. The deficient practice posed a risk to the health and safety of residents if staff were unable to recognize the signs and symptoms of TB.

findings: 1. A review of E1's and E2's personnel records revealed TB signs and symptoms training dated September 23, 2023. However, there was no current documentation of TB signs and symptoms training. 2. In an interview, E1 reviewed the findings and no additional documentation was provided for review.

rule: R9-10-703.K.8.a-c. Administration K. An administrator shall: 8. Maintain a written log of unauthorized absences for at least 12 months after the date of a resident’s absence that includes the: a. Name of a resident absent without authorization, b. Name of the individual to whom the report required in subsection (K)(6) was submitted, and c. Date of the report; and

evidence: Based on documentation review, record review, and interview, the administrator failed to maintain a written log of unauthorized absences for at least 12 months after the date of a resident's absence that included the name of the resident, name of the individual to whom the report was submitted, and date of the report.

findings: 1. A review of R1's medical record revealed an Arizona Department of Child Safety (DCS) incident report dated September 11, 2025, at 6:45 AM. The report stated, "... [R1]... Describe Event or Incident; Prior to Incident: At the above date and time, staff were conducting the routine morning wake-up for client's. [R1's] bed appeared occupied, however, upon closer inspection, staff discovered [R1] had constructed a makeshift dummy to resemble a person lying in bed; During the Incident: Staff immediately searched the grounds and determined that [R1] was not present. [R1's] absence was reported as AWOL (Absent Without Leave). Staff maintained awareness of other clients' safety and continued monitoring the environment while attempting to confirm [R1's] whereabouts; After the Incident: Staff contacted Chandler Police Department to report [R1] as AWOL. Law enforcement responded to the facility and completed AWOL report. At the time of this report, [R1's] whereabouts remained unknown; Describe Steps Taken to Prevent Incident at the Time of Incident and in the Future; Prior to Incident: The agency was actively engaged in supporting the client through individualized behavioral interventions. The treatment team focused on the following goals: eliminating illegal behaviors and consistently complying with home, school, and community expectations. Maintaining abstinence from mood-altering substances. Developing essential skills needed to sustain a drug-free lifestyle; Actions Taken After the Incident: Following the incident, the agency implemented the following responses and continued support interventions: Upon the client's return from runaway status, the clinical team will resume structured behavioral interventions targeting coping skills, emotional regulation, and conduct-disordered behaviors. The agency will continue working with the client to build accountability and reinforce the importance of safe, appropriate behavior in both residential and community settings. The client will receive ongoing education and support to reduce the likelihood of recidivism and maintain abstinence from substances. The client's individualized treatment plan will be reviewed and revised as needed to address any new risk factors or challenges identified during this episode; Witnesses: [E3]; BHT; Child Abuse Hotline Notification: Yes; 9/11/25; Law Enforcement: Yes; Chandler Police; Police Report Number: [redacted]; Record of Verbal Notification: DCS Specialist/Supervisor; [O1]; 9/11/25; 7:55 AM..." 2. A review of facility documentation revealed a policy titled, "AWOL: A resident is considered AWOL anytime that they purposefully leave Staff's supervision and/or sight without permission. Note: this includes purposefully evading or hiding from staff even if the resident is still in the home or on property. In order to protect the safety of our residents and members of the community, takes the following steps to address AWOLs: 1. When a child verbalizes he is going to go AWOL, the staff will attempt to provide one-to-one counseling to address the youth's needs and fears; 2. If a youth leaves the facility, agency staff will continue to verbally attempt to get him to return through the house. However, staff cannot take any action that jeopardizes the safety of other residents or leave the other residents unsupervised ; 3. If a child's whereabouts are unknown staff will immediately conduct a thorough search of the residence & grounds; 4. Once AWOL, a youth will be given a limited amount of time, typically up to 2 hours, to return to the residence on their own. If a youth does not return within the established time limit, the Police will be contacted and a "Missing Persons Report" will be filed. Additionally, agency staff will contact the family and Placement worker to inform them that the youth is AWOL; 5. When a youth returns, staff will conduct a search of the youth and all the personal belongings to ensure that no contraband is brought into the house. Additionally, the agency staff will inform the family & Placement Worker of the youths return.; 6. Because of the safety risk youths who AWOL will typically lose all privileges and require additional supervision upon their return; 7. An incident report with all pertinent information will be sent to a youth's clinical team within 1 hour. In the incident report, it will also include the dates and times when the incident was reported to the resident's representatives. Ie. Parents, guardians, probation officer, etc..." 3. A review of facility documentation revealed an AWOL log. However, the AWOL log did not contain any documentation or information regarding R1's incident. 4. In an interview, E1 reviewed the findings and reported E1 created the incident report through the DCS portal but did not add any information to the AWOL log.