summary: Compliance (Annual) - 5/1/2025

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on May 1, 2025:

rule: R9-10-707.A.8.a. Admission; Assessment A. An administrator shall ensure that: 8. If a behavioral health assessment is conducted by a: a. Behavioral health technician or registered nurse, within 24 hours a behavioral health professional, certified or licensed to provide the behavioral health services needed by the resident, reviews and signs the behavioral health assessment to ensure that the behavioral health assessment identifies the behavioral health services needed by the resident; or

evidence: Based on record review and interview, the administrator failed to ensure if a behavioral health assessment was conducted by a behavioral health technician (BHT) or registered nurse, within 24 hours a behavioral health professional (BHP), certified or licensed to provide the behavioral health services needed by the resident, reviewed and signed the behavioral health assessment to ensure the behavioral health assessment identified the behavioral health services needed by the resident, for one of two residents sampled. The deficient practice posed a risk as an analysis of the resident's needs for behavioral health services was not reviewed within 24 hours to ensure the behavioral health assessment identified the behavioral health services needed by the resident.

findings: 1. A review of R2's (admitted in 2025) medical record revealed a behavioral health assessment (dated in 2025). The assessment was signed and dated by E8, a BHT. However, the assessment was signed and dated by E2, the BHP, approximately three days after E8 conducted the assessment. 2. In an interview, E1 reported the date E2 signed the assessment may have been a mistake. 3. In a joint exit interview, the findings were reviewed with E1, E8, and E9 and no additional comments, statements, or documentation were provided regarding the findings.

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

evidence: Based on record review and interview, the administrator failed to ensure 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, for one of two residents sampled. The deficient practice posed a risk as a description of the resident's behavioral health services to be provided was not reviewed within 24 hours to ensure the treatment plan was complete and accurate.

findings: 1. A review of R2's (admitted in 2025) medical record revealed a treatment plan (dated in 2025). The treatment plan was signed and dated by E8, a BHT. However, the treatment plan was signed and dated by E2, the BHP, approximately three days after E8 completed the assessment. 2. In an interview, E1 reported the date E2 signed the treatment plan may have been a mistake. 3. In a joint exit interview, the findings were reviewed with E1, E8, and E9 and no additional comments, statements, or documentation were provided regarding the findings.

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

findings: 1. A review of Department documentation revealed BH5029 was licensed to provide behavioral health services to individuals whose behavioral health issue limits the individuals' ability to function independently (individuals under 18 years of age). 2. A review of facility documentation revealed a document titled "Incident Report" (dated in 2025). The report stated " ... At approximately 5:50pm [R2] joined [R3] and [R2] and [R3] were observed jumping over the wall of the property going AWOL. BHRF followed AWOL protocol and attempted to redirect them back to the home; however, [R2] and [R3] ran to avoid staff redirection. BHRF followed AWOL protocol and called Glendale Police to the AWOL. … An officer arrived on site to gather more information regarding the member, [R3], and their potential location. [R3’s] juvenile probation officer called the BHRF to inform them that [R2] and [R3] had arrived at [R3’s] [parent’s] house. PD was updated on the member’s location and the member was returned to the BHRF at approximately 10:00PM. 3. A review of facility documentation revealed a daily staffing schedule. The staffing schedule revealed two personnel members were scheduled to work on the date and time of R2’s and R3’s unauthorized absence. 4. In an interview, E1 reported personnel members did not follow R2 and R3. E1 reported R2 and R3 ran away after a personnel member attempted to redirect the residents back to the facility. E1 reported facility protocol was to make notifications, attempt to locate and redirect the resident. E1 reported personnel members do not follow residents to prevent residents from running into the street. 5. In a joint exit interview, the findings were reviewed with E1, E8, and E9 and no additional comments, statements, or documentation were provided regarding the findings.

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 observation, record review, and interview, the administrator failed to ensure a resident did not have access to any furnishing that may present a threat to the resident's health or safety based on the resident's personal history. The deficient practice posed a risk to the health and safety of R2 as the bunk bed posed a ligature hazard, R2 could jump off the bed, and both situations could cause R2 to suffer physical injury.

findings: 1. The Compliance Officer observed a bunk bed in R2’s bedroom. The bunk bed appeared to be made of solid wood. 2. A review of R2's (admitted in 2025) medical record revealed a behavioral health assessment (dated in 2025). The assessment stated " ... member has attempted suicide multiple times. Member reported [R2] has attempted suicide by laying down on railroad tracks to be run over by a train, tried shooting [R2] with [R2’s] [parent’s] fun, and has jumped off roofs. … Member has been in [hospital] for approximately 1 month for suicidal ideation and self-harming (superficial cuts to [R2’s] arm).” 3. In a joint exit interview, the findings were reviewed with E1, E8, and E9 and no additional comments or statements were provided regarding the findings.


state: AZ

facility_name: MISS A'S LLC

summary: Compliance (Annual) - 5/9/2024

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on May 9, 2024:

inspection_type: Compliance (Annual)

rule: A.R.S. § 36-407. Prohibited acts; required acts A. A person shall not establish, conduct or maintain in this state a health care institution or any class or subclass of health care institution unless that person holds a current and valid license issued by the department specifying the class or subclass of health care institution the person is establishing, conducting or maintaining. The license is valid only for the establishment, operation and maintenance of the class or subclass of health care institution, the type of services and, except for emergency admissions as prescribed by the director by rule, the licensed capacity specified by the license.

evidence: Based on observation, documentation review, record review, and interview, the administrator failed to maintain a health care institution with the approved operations of the subclass of health care institution for which the Department issued a valid license. The deficient practice posed a risk as the licensed health care institution was not authorized to provide respite services.

findings: R9-10-716(A)(1)(b) An administrator shall ensure that: 1. 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. 1. The Compliance Officer observed three residents on the premises of BH5029 when the Compliance Officer arrived at 8:07AM. 2. The Compliance Officer observed three individuals arrive at and enter the premises at 8:12AM. 3. The Compliance Officer observed one of the residents from BH5029 leave the premises. 4. In an interview, E6 reported the 3 individuals who entered the premises at 8:12AM were from another licensed health care institution. E6 reported the three residents from another licensed health care institution came to BH5029 to do school online. 5. The Compliance Officer observed there were now five individuals on the premises of BH5029: two were residents of BH5029 and three were residents from another licensed health care institution. 6. A review of Department documentation revealed BH5029 was approved for a licensed capacity of eight residents under the age of 18 (effective December 8, 2016). 7. A review of Department documentation revealed BH5029 was not authorized to provide respite services. 8. A review of Department documentation revealed a confidential resident roster for BH6116. The roster revealed O1 was a resident at BH6116. 9. A review of facility documentation revealed a scope of services (date unavailable). The scope of services did not include respite services. 10. A review of resident medical records revealed medical records were not available for review for the three residents from BH6116. 11. In an interview, E1 reported behavioral health assessment were conducted for the three residents from BH6116 for their admission to BH6116. 12. In an interview, E1 reported BH5029 was never over capacity of eight residents. 13. In an interview, E1 reported the three residents from BH6116 come to BH5029 to do school online. 14. In an interview, E1 reported behavioral health services and personal care services were not provided to the three residents from BH6116. E1 reported there were no staffing concerns for the BH6116, however, E1 reported it was easier to bring the residents from BH6116 so the residents could be supervised by one personnel member instead of two. 15. In an interview, E1 reported E1 did not agree with the findings.

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 a training program for all staff regarding fall prevention and fall recovery to include continued competency training.

findings: 1. A review of facility documentation revealed a policy and procedure titled "A.R.S. 26-420.01 - Fall Prevention and Fall Recovery" (dated April 28, 2024). The policy and procedure stated "Miss A's has developed and administered a training program for all staff regarding fall prevention and fall recovery. The training shall include initial training and continued competency training in fall prevention and fall recovery. ... Upon hire, all staff who work with the members at Miss A's BHRF will complete this training." However, the training program did not include continued competency training. 2. In an interview, the findings were reviewed with E1 and no additional comments or statements were provided regarding the findings.

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 if E5 was unable to meet a resident's needs during an accident or emergency, and the facility's standards were not followed.

findings: 1. A review of the facility's policies and procedures revealed a policy titled "CPR and First Aid" (dated April 28, 2024). The policy stated "All Owners, Behavioral Health Professionals and Behavioral Health Technicians associated to Miss 's, will have the required cardiopulmonary resuscitation, (CPR) and first aid training that includes a demonstration during employee orientation of hands on training. ... Should a potential employee not have hands-on CPR and/or First Aid training the candidate will be enrolled in the hands-on class prior to being hired or will not work along; Class will be a hands-on training ... View demonstration of the CPR will be performed ensuring knowledge and ability." 2. A review of facility documentation revealed a daily staffing schedule for May 2024. The schedule revealed E5 was scheduled to work alone on the following dates and the following times: -10:00PM to 6:00AM: May 6-9, 2024. 3. A review of E5's (hired in 2022) personnel record revealed E5 was hired as a behavioral health technician (BHT). The record revealed documentation of CPR training from "NationalCPRFoundation" issued April 15, 2024. The document stated "Valid for 2 years." 4. A review of the "NationalCPRFoundation" website revealed courses were conducted online. The "NationalCPRFoundation" website stated the following: -"Help Save Lives Today with Your Online CPR Certification Training!" -"All courses can be completed online in just a few hours or less. Once you have completed an examination via our quick and easy online system, you will receive a PDF copy of your certificate immediately via email as well as your card within 2-5 business days;" and -"Online training is a legal and acceptable form of training, however, NCPRF\'ae does not offer in-person training. Your employer or licensing board may require in-person training for "special industries". You should consult with your employer if you have questions about whether our certification will be accepted. Therefore, we cannot guarantee that our certification will be accepted in every situation." 5. In an interview, E1 reported E1 did not observe E5's demonstration of hands on [CPR] training. 6. In an interview, E1 reported E5 reported E5 went to an in-person demonstration after the CPR course. E1 reported this information was not documented. 7. In an interview, E8 reported E8 spoke with a representative from NationalCPRFoundation. E8 reported the representative reported individuals who take the course from NationalCPRFoundation do a demonstration after the course. E8 reported E8 would send this information to the Compliance Officer, however, this information was not provided for review. 8. In an interview, the findings were reviewed with E1 and no additional comments or statements were provided regarding the findings.

rule: A. An administrator shall ensure that: 3. An order is: c. If the order is a verbal order, authenticated by the medical practitioner or behavioral health professional issuing the order;

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure medication administered to a resident was administered in compliance with an order, for one of two residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper medication administration.

findings: R9-10-101.26 "Authenticate" means to establish authorship of a document or an entry in a medical record by: a. A written signature; b. c. d. An individual ' s initials, if the individual ' s written signature appears on the document or in the medical record; A rubber-stamp signature; or An electronic signature code. 1. A review of facility documentation revealed a scope of services (date unavailable). The scope of services stated " ... Miss A's stresses the importance of medication management to assist in challenging behaviors." 2. In an interview, E1 reported BH5029 does not provide assistance in the self-administration of medication. E1 reported medication administration was provided to residents. E1 updated the scope of services. 3. A review of facility documentation revealed an updated scope of services. The scope of service stated " ... Miss A's stresses the importance of medication management to assist in challenging behaviors as well as medication administration." 4. A review of R2's medical record revealed a treatment plan (dated in 2024). However, R2's treatment plan did not include whether medication administration or assistance in the self-administration of medication was to be provided to R2. 5. A review of R2's medical record revealed "Fluoxetine HCL 10mg" was documented as provided on the following dates and the following times: -May 7, 2024: 5:53AM; -May 8, 2024: 5:55AM; and -May 9, 2024: 5:55AM. 6. A review of R2's medical record revealed "Guanfacine 1mg" was documented as provided on the following dates and the following times: -May 8, 2024: 5:55AM and 8:05PM; and -May 9, 2024: 5:55AM. 7. A review of R2's medical record revealed medication orders (dated March 4, 2024). The medication orders stated: -"Fluoxetine 10mg 1xDaily 8AM;" -"Guanfacine 1mg 2x Daily 8AM/8PM." 8. In an interview, E1 reported R2 goes to school early in the morning so R2's medications were administered early. 9. In an interview, E1 reported this was not considered a medication error because R2's medical practitioner was aware R2 received R2's morning medications early. E1 reported R2's medical practitioner gave a verbal order for the aforementioned medications to be administered early. However, the verbal order was not documented and authenticated by the medical practitioner or behavioral health professional issuing the order. 10. In an interview, E1 acknowledged a verbal order was not authenticated by the medical practitioner or behavioral health professional issuing the order.

rule: A. An administrator shall ensure that: 6. Before a resident participates in behavioral health services provided in a setting or activity with more than one resident participating, the diagnoses, treatment needs, developmental levels, social skills, verbal skills, and personal histories, including any history of physical or sexual abuse, of the residents participating are reviewed to ensure that the: a. Health and safety of each resident is protected, and

evidence: Based on observation, documentation review, record review, and interview, the administrator failed to ensure before a resident participated in behavioral health services provided in a setting or activity with more than one resident participating, the diagnoses, treatment needs, developmental levels, social skills, verbal skills, and personal histories, including any history of physical or sexual abuse, of the residents participating were reviewed to ensure the health and safety of each resident was protected. The deficient practice posed a risk as the licensed health care institution was not authorized to provide respite services.

rule: B. If a behavioral health residential facility provides medication administration, an administrator shall ensure that: 3. A medication administered to a resident: a. Is administered in compliance with an order, and

findings: 1. A review of facility documentation revealed a scope of services (date unavailable). The scope of services stated " ... Miss A's stresses the importance of medication management to assist in challenging behaviors." 2. In an interview, E1 reported BH5029 does not provide assistance in the self-administration of medication. E1 reported medication administration was provided to residents. E1 updated the scope of services. 3. A review of facility documentation revealed an updated scope of services. The scope of service stated " ... Miss A's stresses the importance of medication management to assist in challenging behaviors as well as medication administration." 4. A review of R2's medical record revealed a treatment plan (dated in 2024). However, R2's treatment plan did not include whether medication administration or assistance in the self-administration of medication was to be provided to R2. 5. A review of R2's medical record revealed "Fluoxetine HCL 10mg" was documented as provided on the following dates and the following times: -May 7, 2024: 5:53AM; -May 8, 2024: 5:55AM; and -May 9, 2024: 5:55AM. 6. A review of R2's medical record revealed "Guanfacine 1mg" was documented as provided on the following dates and the following times: -May 8, 2024: 5:55AM and 8:05PM; and -May 9, 2024: 5:55AM. 7. A review of R2's medical record revealed medication orders (dated March 4, 2024). The medication orders stated: -"Fluoxetine 10mg 1xDaily 8AM;" -"Guanfacine 1mg 2x Daily 8AM/8PM." 8. In an interview, E1 reported R2 goes to school early in the morning so R2's medications were administered early. 9. In an interview, E1 reported this was not considered a medication error because R2's medical practitioner was aware R2 received R2's morning medications early. E1 reported R2's medical practitioner gave a verbal order for the aforementioned medications to be administered early. However, the verbal order was not documented and authenticated by the medical practitioner or behavioral health professional issuing the order. 10. In an interview, E1 acknowledged medication administered to a resident was not administered in compliance with an order.


facility_name: STREETLIGHTUSA

summary: Modification - 4/29/2025

raw_content: No deficiencies were found during the onsite modification inspection conducted on April 29, 2025.

inspection_type: Modification


summary: Compliance (Annual) - 3/4/2025

raw_content: The following deficiency was found during the on-site compliance inspection conducted on March 4, 2025:

rule: R9-10-706.B.2.a. Personnel B. An administrator shall ensure that: 2. A personnel member's skills and knowledge are verified and documented: a. Before the personnel member provides physical health services or behavioral health services, and

evidence: Based on documentation review, and interview, the administrator failed to ensure a personnel member's skills and knowledge were verified and documented before the personnel member provided behavioral health services. The deficient practice posed a risk to the health and safety of residents if a personnel member was unqualified or unsafe to work in a healthcare institution.

findings: In a documentation review of E3's personal file revealed, E3 had a hire date of December 4, 2024. In a documentation review of E3's personal file revealed, E3's skills and knowledge were not verified nor documented before E3 provided behavioral health services. In an interview, E1 acknowledged E3's skills and knowledge were not verified nor documented before E3 provided behavioral health services. In an exit interview, the findings were reviewed with E1, and no further documentation or comment was provided.


summary: Complaint - 9/10/2024

raw_content: This new Statement of Deficiencies supersedes the Statement of Deficiencies sent to the licensee on October 16, 2024. An on-site investigation of complaint AZ00215771 was conducted on September 10, 2024 and the following deficiencies were cited.

inspection_type: Complaint

evidence: Based on documentation review, record review, and interview, the administrator failed to develop and administer a training program for all staff regarding fall recovery. The training program did not include initial training and continued competency training in fall recovery, for two of six personnel records sampled. The deficient practice posed a health and safety risk to residents if they were to fall and staff could not safely assist in recovering the resident.

findings: 1. A review of facility documentation revealed the facility used "Relias: Slips, Trips, and Falls" for fall prevention training. 2. A review of E2's and E5's personnel records revealed competency training in fall prevention. However, documentation of competency training in fall recovery was not available for review. 3. In an interview, O1 acknowledged E2's and E5's personnel record did not include training in fall recovery.

rule: B. An administrator shall ensure that: 2. A personnel member's skills and knowledge are verified and documented: a. Before the personnel member provides physical health services or behavioral health services, and b. According to policies and procedures; and

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel member's skills and knowledge were verified and documented before the personnel member provided behavioral health services, and according to policies and procedures, for two of six personnel records sampled. The deficient practice posed a risk if personnel members were unable to meet a resident's needs.

findings: 1. A review of facility documentation revealed a policy and procedure titled "JOB DESCRIPTIONS, DUTIES, AND QUALIFICATIONS." The policy and procedure stated "A personnel member's skills and knowledge are verified and documented, before the personnel member provides physical health services or behavioral health services." 2. A review of facility documentation revealed a policy and procedure titled "JOB DESCRIPTIONS, DUTIES, AND QUALIFICATIONS." The policy and procedure stated "Behavioral Health Paraprofessional (BHPP): An individual who provides health related services at or for a health care institution, under supervision by a BHP (b). ....The Sanctuary shall comply with the requirements for behavioral health technicians and behavioral health paraprofessionals in R9-10-115. " 3. A review of facility documentation revealed a staffing schedule, the schedule stated R1 was scheduled to work on the following dates: - August 05, 2024 - August 06, 2024 - August 07, 2024 - August 12, 2024 - August 13, 2024 - August 14, 2024 - August 20, 2024 - August 21, 2024 - August 26, 2024 - August 27, 2024 - August 28, 2024 - September 02, 2024 - September 03, 2024 - September 04, 2024 - September 09, 2024 - September 10, 2024 - September 11, 2024 4. A review of facility documentation revealed a staffing schedule, the schedule stated R5 was scheduled to work on the following dates: - August 07, 2024 - August 08, 2024 - August 09, 2024 - August 10, 2024 - August 14, 2024 - August 15, 2024 - August 16, 2024 - August 17, 2024 - August 21, 2024 - August 22, 2024 - August 23, 2024 - August 24, 2024 - August 28, 2024 - August 29, 2024 - August 30, 2024 - August 31, 2024 - September 04, 2024 - September 05, 2024 - September 06, 2024 - September 07, 2024 - September 11, 2024 - September 12, 2024 - September 13, 2024 - September 14, 2024 5. A review of E1's (hired in 2023) personnel record revealed E1 was hired as a Behavioral Health Paraprofessional. However, documentation of verification of skills and knowledge was not available for review. 6. A review of E5's (hired in 2024) personnel records revealed E5 was hired as the Behavioral Health Paraprofessional. However, documentation of verification of skills and knowledge was not available for review. 7. In an interview, E1 reported verification of skills and knowledge was completed but not documented. 8. In an interview, O1 acknowledged documentation of verification of skills and knowledge for E1 and E5 was not available for review.

rule: B. An administrator shall ensure that: 3. Sufficient personnel members are present on a behavioral health residential facility's premises with the qualifications, experience, skills, and knowledge necessary to: a. Provide the services in the behavioral health residential facility's scope of services, b. Meet the needs of a resident, and c. Ensure the health and safety of a resident.

evidence: Based on documentation review, record review and interview, an administrator failed to ensure sufficient personnel members are present on a behavioral health residential facility's premises with the qualifications, experience, skills, and knowledge necessary to, provide the services in the behavioral health residential facility's scope of services, meet the needs of a resident, and ensure the health and safety of a resident. The deficient practice posed a risk as sufficient personnel were not present to meet the resident's needs and ensure the health and safety of residents.

findings: 1. A review of the facility documentation revealed a policy titled "Client Supervision" dated March 21, 2024. The policy stated "ADHS - A.R.S. 36-401 "Supervision means directly overseeing and inspecting the act of accomplishing a function or activity." 2. A review of facility documentation revealed a policy titled "Staff Coverage, Ratio and Supervision" dated May 2024. The policy stated, " In an effort to minimize the risk of harm to residents, SLUSA will staff the BHRF in the following staffing patterns filled by persons who reflect the cultural and ethnic characteristics of the residents in care as much as possible. SLUSA will provide twenty-four (24) hours per day, seven (7) days per week monitoring of residents during the day and sleeping hours." 3. A review of facility documentation revealed a policy titled "Staff Coverage, Ratio and Supervision" dated May 2024. The policy stated "Supervision of Residents inside the bedrooms: Bedroom checks shall be carried out at intervals not exceeding fifteen (15) minutes. During the Bedroom check, staff members shall not only confirm the resident's presence, but will also assess for any potential risk..." 4. A review of facility documentation revealed a policy titled "Job Description, Duties, and Qualifications." The policy stated. "The Sanctuary will ensure that sufficient personnel members are present on the premises with the qualifications, experience, skills, and knowledge necessary to. Provide the services in The Sanctuary's scope of services. Meet the needs of the clients. Ensure the health and safety of a client." 5. A review of facility documentation revealed a incident report dated September 05, 2024. The incident report stated, "On 09/05/2024, [E4] requested [R1] be brought to the therapy office once completed with another scheduled meeting. Resident [R1] was brought to the therapist's office at approximately 1:30-1:40. [R1] disclosed to the therapist that another peer was kissing [R1] and asking [R1] to engage in other sexual activity. The resident identified the additional sexual behavior as allowing a peer to " finger [R1]." The resident disclosed that the incident happened after 8:00 pm. The resident was requesting to move the cottages due to the incident. This therapist spoke to the program manager [E1] and RSM [E3] regarding the incident. The program manager was able to locate the incident through the video system. The video shows resident [R1] lingering outside of the restroom and shortly after resident [R2] making motions to [R1] from bedroom #4 doorway. The motions were suggestive of reeling someone in. Shadows were visible and appeared to be kissing and touching one another. One shadow appeared to get on their knees at a face to genital level with the other shadow. Another portion of the video appeared to have one resident lift their shirt while the other resident appeared to be using their mouth on the other resident's chest. One section of the video appears to have the residents inside bedroom #4 where there were no camera angles that could view what took place during these moments. The video footage was time stamped 8:22 pm when the first " kissing " was observed. [R1] exited bedroom #4 at 8:28 PM but returns at 8:29 pm and exits again at 8:31 PM. Another resident [R3] can be seen walking to bedroom #4 but quickly walking away. [R1] was interviewed by this therapist and the Group Facilitator [E4]. Residents stated that resident [R2] was touching [R1] " private parts " in addition to kissing. The resident denied digital penetration. The resident admitted to kissing and stated that the kissing had initially started weeks before the incident. [R2] states that [R2] was playing a game with other residents in which the residents were playing around and pretending to kiss. Resident states that when [R1] leaned in to pretend to kiss peer [R2] kissed [R1]. [R1] reported to feel uncomfortable and like [R1] was coerced. Client initially stated [R1] did not want to tell [R2] no but was afraid peer would get mad. [R1] later stated that [R1] said no but peer continued. 6. A review of facility footage dated September 5, 2024 revealed staff were in two separate locations of the cottage which did not provide a line of sight to room number four to provide continuous protective oversight to meet the needs of residents and ensure the health and safety. 7. A review of facility documentation dated September 5, 2024 revealed that in the 19 minutes of video footage, personnel did not conducted bedroom checks. 8. In a joint interview, O1 and O2 reported E4 was working on a project with another resident and E5 was assisting with medications. 9. In a joint interview, O1 and O2 acknowledged staff 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, provide the services in the behavioral health residential facility's scope of services, meet the needs of a resident, and ensure the health and safety of a resident.

rule: A. An administrator shall ensure that: 8. If a behavioral health assessment is conducted by a: a. Behavioral health technician or registered nurse, within 24 hours a behavioral health professional, certified or licensed to provide the behavioral health services needed by the resident, reviews and signs the behavioral health assessment to ensure that the behavioral health assessment identifies the behavioral health services needed by the resident; or

evidence: Based on record review and interview, the administrator failed to ensure if a behavioral health assessment was conducted by a behavioral health technician (BHT) or registered nurse (RN), within 24 hours a behavioral health professional (BHP), certified or licensed to provide the behavioral health services needed by the resident, reviewed and signed the behavioral health assessment to ensure the behavioral health assessment identified the behavioral health services needed by the resident, for two of two residents sampled. The deficient practice posed a risk as an analysis of the resident's needs for behavioral health services to determine which services a health care institution would provide was not reviewed.

findings: 1. A review of R1's medical record revealed documentation of behavioral health assessment dated April 2024. However, the assessment was not signed by a behavioral health professional. 2. A review of R2's medical record revealed documentation of behavioral health assessment dated July 2024. However, the assessment was not signed by a behavioral health professional. 3. In an interview, O1 acknowledged R1's and R2's behavioral assessment was not signed by a behavioral health professional.

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

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

findings: 1. A review of facility documentation revealed a policy and procedure titled "Client Treatment Planning." The policy stated "Each client's treatment plan will include:... The signatures of the client of the client's representative, and date signed, or documentation of the refusal to sign." 2. A review of R1's medical record revealed a treatment plan was completed July 2024. However, the treatment plan did not include the signature of the resident's representative (legal guardian). 3. A review of R1's medical record revealed a treatment plan was completed September 2024. However, the treatment plan did not include the signature of the resident's representative (legal guardian). 4. In an interview, O1 acknowledged the aforementioned treatment plans had not been signed by the resident representatives (legal guardians). E1 reported having issues scheduling with the resident representatives (legal guardians).

rule: A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that: 4. Includes: f. The signature of the personnel member who developed the treatment plan and the date signed;

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a treatment plan was developed and implemented for each resident to include the signature of the personnel member who developed the treatment plan and the date signed, for one of two residents sampled.

findings: 1. A review of facility documentation revealed a policy and procedure titled "Scope of Services." The policy stated, "The Sanctuary approaches child sexual exploitation (CSE) and co-morbid needs from a complex, developmental, and neuropsychological trauma lens. We utilize evidence-based treatment measures and interventions in order to ensure qualitative care. Our model allows us to not only create efficacious treatment plans to maximize efficacy, it also allows us to support growing clinical knowledge of treatment for this unique population. The treatment modalities that structure our program can be found in leading trauma healing residential centers throughout the U.S., as well as in some of the most well respected academic and research establishments." 2. A review of facility documentation revealed a policy and procedure titled "Client Treatment Planning." The policy stated "Each client's treatment plan will include: The client's presenting issue, the physical health services or behavioral health services to be provided to the client, the signatures of the client of the client ' s representative, and date signed, or documentation of the refusal to sign, the date when the client ' s treatment plan will be reviewed, if a discharge date has been determined, the treatment need after discharge, the signature of the personnel member who developed the treatment plan and the date signed." 3 A review of R1's medical record revealed a treatment plan completed August 2024. However, the treatment plan was not reviewed and signed by the personnel member who developed the treatment plan and the date signed. 4. A review of R1's medical record revealed two treatment plans completed in September 2024. However, the treatment plans were not reviewed and signed by the personnel member who developed the treatment plans and the date signed. 5. In an interview, O1 acknowledged the administrator failed to ensure a treatment plan was developed and implemented for each resident to include the signature of the personnel member who developed the treatment plan and the date signed.

rule: A. An administrator shall ensure that: 2. If a behavioral health residential facility is licensed to provide behavioral health services to individuals whose behavioral health issue limits the individuals' ability to function independently, a resident admitted to the behavioral health residential facility with limited ability to function independently receives: b. Continuous protective oversight;

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure, if a behavioral health residential facility was licensed to provide behavioral health services to individuals whose behavioral health issue limits the individuals' ability to function independently, a resident admitted to the behavioral health residential facility with limited ability to function independently received continuous protective oversight. The deficient practice posed a risk to health and safety of residents under the age of 18, who required continuous protective oversight.

findings: 1. A review of the facility documentation revealed a policy titled "Client Supervision" dated March 21, 2024. The policy stated "ADHS - A.R.S. 36-401 "Supervision means directly overseeing and inspecting the act of accomplishing a function or activity." 2. A review of facility documentation revealed a policy titled "Staff Coverage, Ratio and Supervision" dated May 2024. The policy stated, "In an effort to minimize the risk of harm to residents, SLUSA will staff the BHRF in the following staffing patterns filled by persons who reflect the cultural and ethnic characteristics of the residents in care as much as possible. SLUSA will provide twenty-four (24) hours per day, seven (7) days per week monitoring of residents during the day and sleeping hours." 3. A review of facility documentation revealed a policy titled "Staff Coverage, Ratio and Supervision" dated May 2024. The policy stated "Supervision of Residents inside the bedrooms: Bedroom checks shall be carried out at intervals not exceeding fifteen (15) minutes. During the Bedroom check, staff members shall not only confirm the resident's presence, but will also assess for any potential risk..." 4. A review of facility documentation revealed a policy titled "Job Description, Duties, and Qualifications." The Policy stated "The Sanctuary will ensure that sufficient personnel members are present on the premises with the qualifications, experience, skills, and knowledge necessary to provide the services in The Sanctuary's scope of services, meet the needs of the clients, eEnsure the health and safety of a client." 5. A review of facility documentation revealed a incident report dated September 05, 2024. The incident report stated, "On 09/05/2024, [E4] requested [R1] be brought to the therapy office once completed with another scheduled meeting. Resident [R1] was brought to the therapist's office at approximately 1:30-1:40. [R1] disclosed to the therapist that another peer was kissing [R1] and asking [R1] to engage in other sexual activity. The resident identified the additional sexual behavior as allowing a peer to " finger [R1]." The resident disclosed that the incident happened after 8:00 pm. The resident was requesting to move to the cottages due to the incident. This therapist spoke to the program manager [E1] and [E3] regarding the incident. The program manager was able to locate the incident through the video system. The video shows resident [R1] lingering outside of the restroom and shortly after resident [R2] making motions to [R1] from bedroom #4 doorway. The motions were suggestive of reeling someone in. Shadows were visible and appeared to be kissing and touching one another. One shadow appeared to get on their knees at a face to genital level with the other shadow. Another portion of the video appeared to have one resident lift their shirt while the other resident appeared to be using their mouth on the other resident's chest. One section of the video appears to have the residents inside bedroom #4 where there were no camera angles that could view what took place during these moments. The video footage was time stamped 8:22 pm when the first " kissing " was observed. [R1] exited bedroom #4 at 8:28 pm but returns at 8:29 pm and exits again at 8:31 pm. Another resident [R3] can be seen walking to bedroom #4 but quickly walking away. [R1] was interviewed by this therapist and the Group Facilitator [E4]. Residents stated that resident [R2] was touching [R1] "private parts" in addition to kissing. The resident denied digital penetration. The resident admitted to kissing and stated that the kissing had initially started weeks before the incident. [R2] states that [R2] was playing a game with other residents in which the residents were playing around and pretending to kiss. Resident states that when [R1] leaned in to pretend to kiss peer [R2] kissed. R1 reported to feel uncomfortable and like [R1] was coerced. Client initially stated [R1] did not want to tell [R2] no but was afraid peer would get mad. [R1] later stated that [R1] said no but peer continued." 6. A review of facility footage dated September 5, 2024 revealed staff were in two separate locations of the cottage which did not provide a line of sight to room number four to provide continuous protective oversight. 7. A review of facility documentation dated September 5, 2024 revealed in the 19 minutes of video footage, personnel did not conducted bedroom checks. 8. In a joint interview, O1 and O2 reported E4 was working on a project with another resident and E5 was assisting with medications. 9. In a joint interview, O1 and O2 acknowledged staff failed to provide continuous protective oversight to residents under the age of 18.


summary: Complaint - 6/10/2024

raw_content: An on-site investigation of complaint AZ00211525 was conducted on June 10, 2024 and no deficiencies were cited.


summary: Complaint - 5/8/2024

raw_content: An on-site investigation of complaint AZ00209988 was conducted on May 8, 2024 and no deficiencies were cited :


summary: Complaint - 4/17/2024

raw_content: An on-site investigation of complaint AZ00209147 was conducted on April 17, 2024 and the following deficiencies were cited:

rule: C. An administrator shall ensure that: 3. Policies and procedures are reviewed at least once every three years and updated as needed;

evidence: Based on documentation review and interview, the administrator failed to ensure policies and procedures were reviewed at least once every three years and updated as needed. The deficient practice posed a health and safety risk to residents if changes were required to be made to improve behavioral health services at the facility and were never updated.

findings: 1. During a documentation review, the Compliance Officer reviewed facility policies and procedures. However, the policies and procedures did not have a clear date on when the policies and procedures were last reviewed. 2. In an interview, O1 reported the policies and procedures had not been reviewed or updated since 2019. O1 acknowledged policies and procedures were to be reviewed at least once every three years and updated as needed.

rule: C. An administrator shall ensure that: 5. Unless otherwise stated: a. Documentation required by this Article is provided to the Department within two hours after a Department request; and

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

findings: 1. The Compliance Officer arrived at the facility at 12:20 PM. 2. The Compliance Officer requested to review the following documentation at 12:40 PM: - Documentation of freedom from infectious tuberculosis for E3; and - Documentation of cardiopulmonary resuscitation training for E2. 3. O1 provided E3's one documentation of freedom from infectious tuberculosis at 4:46 PM. 4. O1 provided E2's documentation of cardiopulmonary resuscitation training at 4:50 PM. 5. In an interview, O1 acknowledged the aforementioned documentation was not provided within two hours after the Department's request.

evidence: Based on documentation review, record review and interview, the administrator failed to ensure a personnel member's skills and knowledge were verified and documentation before the personnel member provided behavioral health services, for eight of nine personnel records sampled. The deficient practice posed a health and safety risk to residents as personnel members were providing services with no documentation of verification of skills and knowledge.

findings: 1. A documentation review revealed a policy and procedure titled "Personnel," which was last reviewed in 2019. The policy stated "Every new staff member will complete a minimum of 40 hours of initial on-boarding, orientation, and job training documented on the On-The-Job Training (OJT) Form....The original completed OJT Form will confirm understanding of P&P's, roles, and responsibilities and will be archived in HR's personnel records." 2. A review of E2's personnel record revealed E2 was promoted to Group Facilitator March 2024. However, no documentation of skills and knowledge verification were documented for review. 3. A review of E3's personnel record revealed E3 was hired as a behavioral health paraprofessional April 2024. However, no documentation of skills and knowledge verification were documented for review. 4. A review of E4's personnel record revealed E4 was hired as a behavioral health professional. However, no documentation of skills and knowledge verification were documented for review. 5. A review of E5's and E6's personnel records revealed E5 and E6 were hired as behavioral health paraprofessionals October 2023. However, no documentation of skills and knowledge verification were documented for review. 6. A review of E7's personnel record revealed E7 was hired as a behavioral health paraprofessional March 2024. However, no documentation of skills and knowledge verification were documented for review. 7. A review of E8's personnel record revealed E8 was hired as a behavioral health paraprofessional September 2023. However, no documentation of skills and knowledge verification were documented for review. 8. A review of E9's personnel record revealed E9 was hired as a behavioral health paraprofessional August 2023. However, no documentation of skills and knowledge verification were documented for review. 9. In an interview, O1 acknowledged there was no documentation of verification of skills and knowledge prior to providing behavioral health services for E2, E4, E5, E6, E7, E8 and E9. O1 reported E3 had not provided services and that E3 had completed orientation that day.

evidence: Based on documentation review, record review and interview, the administrator failed to ensure sufficient personnel members were present at a behavioral health residential facility's premises. The deficient practice posed a safety risk to residents as the personnel member to resident ratio was not followed and a resident was able to injure themselves.

findings: 1. A review of facility documentation revealed "Scope of Services," which stated "The Sanctuary Services Include:...Staff to client ratio of 1:3 to 2:5. 2. A review of R2's resident record revealed an individual counseling session note from April 16th at 5:00 PM. The counseling session was of an incident which stated "Client had left the cottage without staff and hid behind a swing set where R2 engaged in self-harm behaviors. Client was bleeding from R2's arm and had a screw in R2's hand. Client ran to staff and asked to speak to therapist. Therapist was called via radio. Client stated R2 was activated by a peer screaming and then being left alone in R2's room (staff has different account and states R2 was sent to R2's room but did not go to R2's room but ran out of the room instead." 3. In an interview, O1 reported all four residents were in the cottage for schooling with one personnel member. O1 reported the one personnel member in the room stayed with the three residents and called on the radio for a personnel member to go after R2. O1 acknowledged the ratio of 1:3 to 2:5 was not kept and there was not sufficient personnel members present to ensure the health and safety of a resident.

rule: E. An administrator shall ensure that: 3. An individual's orientation is documented, to include: a. The individual's name, b. The date of the orientation, and c. The subject or topics covered in the orientation;

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure an individual's orientation was documented to include the subject or topics covered in the orientation, for nine of nine personnel records sampled.

findings: 1. 1. A documentation review revealed a policy and procedure titled "Personnel," which was last reviewed in 2019. The policy stated "Every new staff member will complete a minimum of 40 hours of initial on-boarding, orientation, and job training documented on the On-The-Job Training (OJT) Form....The original completed OJT Form will confirm understanding of P&P's, roles, and responsibilities and will be archived in HR's personnel records." 2. Further documentation review revealed a policy and procedure titled "Documentation of Orientation," which was last reviewed in 2019. The policy stated "An individual's orientation will be documented on their "On-the-Job Training Task List". The documentation will include: the individual's name, the date of the orientation, the subject or topics covered in the orientation." 3. A review of E1's, E3's, E4's, E5's, E6's, E7's, E8's, and E9's personnel record revealed a certificate from Relias indicating completed orientation. However, the orientation documentation did not include the subject or topics covered in the orientation. 4. In an interview, O1 acknowledged the orientation documentation was incomplete as it did not include the subject or topics covered in the orientation.

rule: G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes: 2. The individual's starting date of employment or volunteer service and, if applicable, the ending date; and

evidence: Based on record review and interview, the administrator failed to ensure a personnel record was maintained for each personnel member which included the individual's starting date of employment, for nine of nine personnel records sampled.

findings: 1. A review of E1's, E2's, E3's, E4's, E5's, E6's, E7's, E8's, and E9's personnel records revealed no starting date of employment. 2. In an interview, O1 provided all personnel members dates of hire once logged into Relias. O1 acknowledged personnel records maintained for each personnel member must include the individual's starting date of employment.

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 the individual's compliance with requirements in A.R.S. \'a7\'a7 36-411(C)(1) for two of nine personnel records sampled, and documentation of the individual's compliance with requirements in A.R.S. \'a7\'a7 36-411(C)(2) for one of nine personnel records sampled. The deficient practice posed a risk if E3 and E7 were unqualified to work in a behavioral health residential facility.

findings: 1. A review of E3's personnel record revealed E3 was hired as a behavioral health paraprofessional April 2024. However, documentation of compliance with requirements in A.R.S. \'a7\'a7 36-411(C)(1)(2) were not available for review. 2. A review of E7's personnel record revealed E7 was hired as a behavioral health paraprofessional March 2024. However, documentation of compliance with requirements in A.R.S. \'a7\'a7 36-411(C)(1) were not available for review. 3. In an interview, O1 reported the new hire process was being reviewed and needs to be streamlined. O1 acknowledged there was no documentation of compliance with requirements in A.R.S. \'a7\'a7 36-411(C)(1) (2) for E3 and no documentation of compliance with requirements in A.R.S. \'a7\'a7 36-411(C)(1) for E7. This is a repeat citation from December 13, 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: g. If the individual is a behavioral health technician, clinical oversight required in R9-10-115;

evidence: Based on record review and interview, the administrator failed to ensure a personnel record was maintained for each personnel member which included documentation of clinical oversight required in R9-10-115, for one of nine personnel records sampled. The deficient practice posed a health risk to residents as E2 had no documentation of clinical oversight as required in R9-10-115.

findings: 1. A review of E2 personnel record revealed E2 was promoted to Group Facilitator March 2024. However, no documentation of clinical oversight as required in R9-10-115 was available for review. 2. A review of R2's medical record revealed the following counseling sessions provided by E2: April 9, April 9, April 10, April 12, April 16, April 17. 3. A review of R3's medical records revealed the following counseling sessions provided by E2: April 9, April 9, April 12, April 17. 4. In an interview, O1 acknowledged E2 did not have documentation of clinical oversight as required in R9-10-115.

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

evidence: Based on record review and interview, the administrator failed to ensure a personnel record was maintained for each personnel member which included documentation of cardiopulmonary resuscitation training according to R9-10-703(C)(1)(e), for two of nine personnel records sampled. The deficient practice posed a safety risk to residents as E4 did not have documentation of cardiopulmonary resuscitation which was taken online and did not include a skills evaluation.

findings: 1. A review of E2's personnel record revealed expired cardiopulmonary resuscitation training, which had expired August 2022. 2. A review of E4's personnel record revealed cardiopulmonary resuscitation training which was completed online and did meet the requirements according to R9-10-703(C)(1)(e). 3. O1 provided a copy of E2's current cardiopulmonary resuscitation training dated April 2, 2024. 4. In an interview, O1 acknowledged E2 did not have current cardiopulmonary resuscitation training from August 2022 to April 2024. O1 acknowledged E2's documentation of cardiopulmonary resuscitation training as required according to R9-10-703(C)(1)(e) was not maintained in E2's personnel record. O1 acknowledged E4's documentation of cardiopulmonary resuscitation training indicated the training was completed online and did not meet the requirements according to R9-10-703(C)(1)(e).

rule: K. An administrator shall ensure that: 5. A registered nurse is present at the behavioral health residential facility or on-call; and

evidence: Based on documentation review, record review and interview, the administrator failed to ensure a registered nurse was present at the behavioral health residential facility or on call. The deficient practice posed a health and safety risk as there was no registered nurse present or on-call in the event of a medication emergency.

findings: 1. A review of facility documentation revealed daily staffing schedules from March 31, 2024 to April 27, 2024. The daily staffing schedules stated "RN On-Call: N/A" for all seven days on each daily staffing schedule. 2. A review of E1's personnel record revealed a contract dated April 12, 2024. 3. In an interview, O1 reported E1 was contracted as of April 12, 2024 however E1 had not began providing services and was completing orientation. O1 acknowledged there was no registered nurse present at the behavioral health residential facility or on-call. This is a repeat citation from February 27, 2024.

rule: A. An administrator shall ensure that: 9. Except as provided in subsection (A)(10), a behavioral health assessment for a resident is completed before treatment for the resident is initiated;

evidence: This RULE is not met as evidenced by: Based on documentation review, record review, and interview, the administrator failed to ensure a behavioral health assessment for a resident was completed before treatment for the resident was initiated, for two of four resident records sampled. The deficient practice posed a health and safety risk to residents if residents received treatment which further hindered their behavioral health diagnoses.

findings: 1. A review of facility documentation revealed a policy and procedure titled "Assessment" which was last reviewed in 2019. The policy stated "Assessment will be completed with all incoming clients. Assessment phase occurs within the first 7-10 days, depending on client's emotional and functional states." 2. A review of R2's medical record revealed R2 was admitted into the behavioral health residential facility April 4, 2024. Further review revealed medication administration records with documentation in the assistance with the self-administration of medication between April 4th and April 11, 2024. However, the behavioral health assessment was not completed until April 11, 2024. 3. A review of R4's medical record revealed R4 was admitted into the behavioral health residential facility February 2, 2024. Further review revealed medication administration records with documentation in the assistance with the self-administration of medication as well as individual counseling sessions between February 16th and February 21, 2024. However, the behavioral health assessment was not completed until February 21, 2024. 4. In an interview, O1 reported assessments were completed within seven days after admission. O1 acknowledged services were provided to R2 and R4 prior to the behavioral health assessment completion.

rule: A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that: 4. Includes: a. The resident's presenting issue; b. The physical health services or behavioral health services to be provided to the resident; c. The signature of the resident or the resident's representative, and date signed, or documentation of the refusal to sign; d. The date when the resident's treatment plan will be reviewed; e. If a discharge date has been determined, the treatment needed after discharge; and f. The signature of the personnel member who developed the treatment plan and the date signed;

evidence: Based on record review and interview, the administrator failed to ensure a treatment plan was implemented for each resident which included the resident's presenting issue and the date when the resident's treatment plan will be reviewed, for two of four resident records sampled. The deficient practice posed a health risk to residents as the treatment plan was incomplete and the services being provided to residents were not improving their behavioral health diagnosis.

findings: 1. A review of R2's medical record revealed a treatment plan dated April 2024. The treatment plan reported R2's presenting issue of "Client presents with a history of trauma and behavioral challenges due to trauma fueled behaviors. Client has several previous diagnosis and will be periodically re-evaluated for updating diagnosis." Additionally, the treatment plan did not include the date when R2's treatment plan would be reviewed. 2. A review of R3's medical record revealed a treatment plan dated February 2024. The treatment plan reported R3's presenting issue of "High risk for continued trafficking." Additionally, the treatment plan did not include the date when R3's treatment plan would be reviewed. 3. In an interview, O1 acknowledged treatment plans needed additional information and did not meet rule. O1 acknowledged R2's and R3's treatment plans did not include full presenting issues or the date when the treatment plan will be reviewed again.

rule: B. An administrator shall ensure that counseling is: 1. Offered as described in the behavioral health residential facility's scope of services, 2. Provided according to the frequency and number of hours identified in the resident's treatment plan, and 3. Provided by a behavioral health professional or a behavioral health technician.

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure counseling was offered as described in the behavioral health residential facility's scope of services and provided according to the frequency and number of hours identified in the resident's treatment plan, for three of four resident records sampled. The deficient practice posed a health risk to residents as the counseling being provided was not targeting residents presenting issues and improving their behavioral health diagnosis.

findings: 1. A review of facility documentation revealed facility Scope of Services, which was last reviewed in 2019. The scope of services stated "Availability of services. Optimal treatment participation would include 1 to 3 individual therapy sessions per week. Optimal treatment participation would include attendance to group therapy sessions 4 to 5 times per week." 2. A review of R2's, R3's, and R4's medical records revealed individual and group counseling sessions. Group counseling sessions were not individualized to each resident and were not provided according to the frequency and number of hours identified in the resident's treatment plans. 3. In an interview, O1 acknowledged residents were not receiving group counseling sessions 4 to 5 times per week. O1 acknowledged group counseling sessions were closer to daily progress notes and did not report how each resident participated in group counseling.

rule: C. An administrator shall ensure that: 2. Each counseling session is documented in a resident's medical record to include: a. The date of the counseling session; b. The amount of time spent in the counseling session; c. Whether the counseling was individual counseling, family counseling, or group counseling; d. The treatment goals addressed in the counseling session; and e. The signature of the personnel member who provided the counseling and the date signed.

evidence: Based on record review, and interview, the administrator failed to ensure each counseling session was documented in a resident's medical record which included the treatment goals addressed in the counseling session. 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 R2's, R3's and R4's medical records revealed group counseling sessions. However, the group counseling sessions mirrored daily progress notes and did not include treatment goals addressed nor did they document resident interaction and participation. 2. A review of R2's, R3's, and R4's medical records revealed individual counseling sessions. However, the individual counseling sessions did not include the treatment goals addressed. In addition, topics such as phone calls, building rapport, and feelings from the weekend were used as individual counseling sessions but were not indicated as a treatment goal in the residents treatment plan. 3. In an interview, O1 acknowledged residents were not receiving group or individual counseling to cure, improve, or palliate their behavioral health issue.

rule: A. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 1. The premises and equipment are: a. Maintained in a condition that allows the premises and equipment to be used for the original purpose of the premises and equipment; b. Cleaned and, if applicable, disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection; and c. Free from a condition or situation that may cause a resident or other individual to suffer physical injury;

evidence: Based on documentation review, record review and interview, the administrator failed to ensure the premises were free from a situation which may cause a resident or other individual to suffer physical injury. The deficient practice posed a safety risk to R2 as R2 injured themselves while the facility was not properly staffed according to their scope of services.

rule: R9-10-113. Tuberculosis Screening B. 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), ii. Was administered within 12 months before the date the individual begins providing services at or on behalf of the health care institution or is admitted to the health care institution, and iii. Includes the date and the type of tuberculosis screening test;

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

findings: 1. A review of E3's personnel record revealed no documentation of evidence of freedom from infectious TB as specified in R9-10-113. However, O1 provided one documentation of evidence of freedom from infectious TB after the two hour timeframe ended. 2. A review of E5's and E6's personnel records revealed Maricopa County TB Healthcards. However, the healthcards did not indicate the type of testing conducted to verify compliance with the requirements specified in R9-10-113, therefore the healthcards were not valid evidence of freedom from infectious TB. 3. A review of E7's, E8's, and E9's personnel records revealed only one documentation of evidence of freedom from infectious TB as specified in R9-10-113. 4. In an interview, O1 acknowledged personnel members were required to have two documentation of evidence of freedom from infectious tuberculosis. O1 acknowledged E3, E7, E8 and E9 had only one documentation of evidence of freedom from infectious tuberculosis. O1 acknowledged E5's and E6's documentation of evidence of freedom from infectious TB was not valid or accepted and did not meet the requirements in R9-10-113.


summary: Complaint - 3/27/2024

raw_content: An on-site investigation of complaint AZ00208152 was conducted on March 27, 2024 and the following deficiency was cited :

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

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

findings: 1. The Compliance Officer observed a shared bathroom assigned to R1. The bathroom contained grab bars mounted to the wall. 2. In an interview, E1 acknowledged the grab bars posed a potential ligature hazard, and the premises was not free from a condition or situation that may cause a resident or other individual to suffer physical injury. Technical assistance was provided on this Rule during the compliance inspection conducted on February 27, 2024.


summary: Compliance (Annual) - 2/27/2024

raw_content: The following deficiency was found during the on-site compliance inspection conducted on February 27, 2024:

evidence: Based on observation and interview, the administrator failed to ensure a registered nurse (RN) was present at the behavioral health residential facility or on-call.

findings: 1. The Compliance Officer requested to review the personnel record for the RN. 2. In an interview, E8 reported the facility did not have a contract with a RN at this time. E8 acknowledged a RN was not present at the behavioral health facility or on-call.


summary: Complaint - 12/13/2023

raw_content: An on-site investigation of complaint AZ00204159 was conducted on December 13, 2023 and the following deficiency was cited :

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 compliance with the requirements of A.R.S. \'a7 36-411(C)(1)(2), for four of five personnel members sampled, and in A.R.S. \'a7 36-425.03(E), for one of five personnel members sampled. The deficient practice posed a risk if E3, E4, E5, and E7 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. A.R.S. \'a7 36-425.03(E) Children's behavioral health program personnel shall certify on forms that are provided by the department and notarized that they are not awaiting trial on or have never been convicted of or admitted in open court or pursuant to a plea agreement to committing any of the offenses listed in section 41-1758.03, subsection B or C in this state or similar offenses in another state or jurisdiction. 1. A review of Department documentation revealed BH5096 was licensed as a children's behavioral health residential facility, effective August 10, 2017. 2. A review of E3's 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 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 personnel record revealed documentation of compliance with A.R.S. \'a7 36-411(C)(1) was not available for review. 5. A review of E7's personnel record revealed a valid fingerprint clearance card. However, documentation of compliance with \'a7 A.R.S. \'a7 36-411(C)(1)(2) was not available for review. 6. A review of E7's personnel record revealed documentation of compliance with A.R.S. \'a7 36-425.03(E) was not available for review. 7. In a joint interview, E1 and E2 acknowledged documentation of compliance with A.R.S. \'a7 36-411(C)(1)(2) and A.R.S. \'a7 36-425.03(E) was not available for review.


summary: Change of Service - 9/1/2023

raw_content: No deficiencies were found during the off-site inspection to amend the facility license to include buildings A and B conducted on September 1, 2023.

inspection_type: Change of Service


facility_name: RMBHS POSADA HOUSE

summary: Compliance (Annual) - 10/10/2025

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on October 10, 2025:

rule: R9-10-703.A.2.a-b. Administration A. A governing authority shall: 2. Establish, in writing: a. A behavioral health residential facility's scope of services, and b. Qualifications for an administrator;

evidence: Based on record review, documentation review, and interview, the governing authority failed to establish, in writing, a behavioral health residential facility's scope of services to include assistance in the self-administration of medication.

findings: 1. A review of R1's medical record revealed the following medication orders: cetirizine 5 mg oral tablet, chewable, one tablet, chew every evening for 30 days as needed for allergy; risperidone 1 mg, by mouth every morning and 1 mg by mouth every evening; Focaline XR 5 mg, by mouth every morning; and Ritalin 5 mg, by mouth every morning. 2. A review of R1's medical record revealed R1 was provided assistance in the self-administration of medication for the following medications: cetirizine 5 mg, give one tablet to chew and swallow in the evening as needed for allergy symptoms, June 6-7, 2025; methylphenidate 5 mg, take one tablet by mouth only in the morning for attention deficit hyperactivity disorder, June 7-8, 2025; Dexmethylphenidate 5 mg, take one capsule by mouth every day in the morning for attention deficit hyperactivity disorder, June 7-8, 2025; and risperidone 1 mg, take one tablet by oral route every morning and at bedtime, June 6-8, 2025. 3. A review of R2's medical record revealed the following medication orders: desmopressin 10 mg mcg/inhaler nasal spray, 30 microgram(s) or three sprays intranasally twice a day; guanfacine ER 2 mg tablet extended release 24 hours, take one tablet by mouth every 8:00 p.m.; and clonidine HCL ER 0.1 mg tablet, extended release 12 hours, take one tablet by mouth every 8:00 p.m. 4. A review of R2's medical record revealed R2 was provided assistance in the self-administration of medication for the following medications: Desmopressin 0.01 spray, use three sprays in the nose twice daily; guanfacine 2 mg ER, take one tablet by mouth once daily at 8:00 p.m.; and clonidine 0.1 mg tablet, take one tablet by mouth once daily at 8:00 p.m. 5. A review of the facility's policies and procedures (dated November 2, 2023) revealed a document titled "Scope of Services." However, the document did not include the assistance in the self-administration of medication service. 6. In an interview, E1 acknowledged the facility's scope of services did not include assistance in the self-administration of medication. 7. In an exit interview, the findings were discussed with E1, and no additional statements or documentation were provided.

rule: R9-10-718.C.4.a. Medication Services C. If a behavioral health residential facility provides assistance in the self-administration of medication, an administrator shall ensure that: 4. Training for a personnel member, other than a medical practitioner or registered nurse, in assistance in the self-administration of medication: a. Is provided by a medical practitioner or registered nurse or an individual trained by a medical practitioner or registered nurse; and

evidence: Based on record review and interview, the administrator failed to ensure training for a personnel member, other than a medical practitioner or registered nurse, in assistance in the self-administration of medication was provided by a medical practitioner or registered nurse or an individual trained by a medical practitioner or registered nurse, for one of three personnel members sampled who provided assistance in the self-administration of medication. The deficient practice posed a risk a resident experienced a change in condition due to improper assistance in the self-administration of medication.

findings: 1. A review of E4's personnel record revealed a certificate of completion (dated December 10, 2024). The certificate indicated E4 completed training in the "[Red Mountain Behavioral Health Services] Medication" course. 2. In an interview, E1 reported E4's training was completed online with no demonstration of E4's skills, was not provided by a medical practitioner or registered nurse, or provided by an individual trained by a medical practitioner or registered nurse. E1 confirmed E4 provided assistance in the self-administration of medication as part of E4's job duties. 3. In an exit interview, the findings were discussed with E1, and no additional statements or documentation were provided.

rule: R9-10-720.B.4. Emergency and Safety Standards B. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 4. A disaster drill for employees is conducted on each shift at least once every three months and documented;

evidence: Based on documentation review and interview, the administrator failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were able to implement a disaster plan.

findings: 1. A review of Department documentation revealed BH5175 had been licensed since July 2017. 2. A review of facility documentation revealed a document titled "Disaster Drill Report" (dated January 17, 2025). However, no documentation of disaster drills for employees conducted on each shift at least once every three months was available. 3. In an interview, E1 reported disaster drills were completed at least once every three months, but acknowledged they were not documented. 4. In an exit interview, the findings were discussed with E1, and no additional statements or documentation were provided.


summary: Complaint;Compliance (Annual) - 9/10/2024

raw_content: The following deficiency was found during the on-site compliance inspection and investigation of complaint AZ00205212 conducted on September 10, 2024:

inspection_type: Complaint;Compliance (Annual)

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

evidence: Based on record review, documentation review and interview, the administrator failed to ensure assistance in the self-administration of medication provided to a resident was in compliance with an order, for one of three residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper assistance in the self-administration of medication.

findings: R9-10-101.24. "Assistance in the self-administration of medication" means restricting a patient ' s access to the patient ' s medication and providing support to the patient while the patient takes the medication to ensure that the medication is taken as ordered. 1. A review of R2's (admitted in 2022) medical record revealed a treatment plan, last updated in August 2024. The treatment plan revealed R2 received assistance in the self-administration of medication. 2. A review of R2's medication orders (last updated May 26, 2023) revealed R2 was prescribed the following medications: -Buspirone 7.5 mg one tablet twice per day; -Lamictal 150 mg one tablet twice per day; -Lexapro 10 mg one tablet daily; -Lexapro 5 mg one tablet daily; -Quetiapine 100 mg one tablet in the morning; -Quetiapine 400 mg one tablet nightly; -Melatonin 3 mg one tablet every bedtime; and -Metformin 500 mg one and a half tablets in the mornings and evenings with meals. 3. A review of R2's medication administration record for the month of November 2023 revealed R2 was provided assistance in the self-administration of medication for the following medications: -Lamotrigine 150 mg one tablet twice per day; -Buspirone 10 mg one tablet twice per day; -Quetiapine 400 mg one tablet daily at bedtime; -Escitalopram 20 mg one tablet daily; -Omega 3 EPA + DHA one capsule twice a day with meals; and -Metformin 500 mg one and a half tablets twice a day with meals. However, on November 25, 2023, the medication administration record indicated Buspirone 10 mg was administered to R2 for the evening dose only. 4. A review of facility documentation revealed an incident report, dated November 26, 2024. The document stated, "After [R2's] weekend session in care concluded, program managers discovered during review of submitted medication logs that medication had not been self-administered [sic] as prescribed. Client's prescription of Buspirone 10mg tablet indicated to take 1 tablet by mouth twice a day. Staff overseeing self-administration [sic] of medication did not administer [sic] twice a day but rather once a day. Client only received 1 tablet in the evenings." 5. In an interview, E1 acknowledged R2 was not administered a medication for which R2 had a medication order. E1 reported the medication error was made by E2. E1 reported R2 had no side effects from the missed medication.


facility_name: MOHAVE MENTAL HEALTH CLINIC, INC - DIAMOND HOUSE

summary: Complaint - 12/4/2025

raw_content: The following deficiency was found during the on-site investigation of complaints 00152328 and 00134820 conducted on December 4, 2025.

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

evidence: Based on record review and interview, the administrator failed to ensure assistance in the self-administration of medication provided to a resident was in compliance with an order. The deficient practice posed a risk to the health and safety of residents if staff were unable to ensure compliance with medication orders.

findings: 1. A review of R2’s medical record revealed a document titled, “Incident, Accident, Death Report Form” dated May 2025. The document stated, “R2 was not given 5:30 PM medication of hydroxyzine pamoate 25 mg capsule.” 2. In an interview, E1 reported the incident occurred. E1 also reported actions were taken by setting an alarm timer in the office for scheduled medications. 3. In an exit interview, the findings were discussed with E1 and no additional comments or documentation were provided.


summary: Complaint - 2/6/2025

raw_content: An on-site investigation of complaint AZ00215533, AZ00221805, and AZ00222793 was conducted on February 6, 2025 and the following deficiencies were cited :

evidence: Based on record review, documentation review, and interview, the administrator failed to ensure assistance in the self-administration of medication provided to a resident was in compliance with an order, for one of one resident sampled. The deficient practice posed a risk as assistance in the self administration of medication could not be verified against a medication order.

findings: 1. A review of Department documentation revealed a complaint for BH5202 stating a staff member reported giving a resident two doses of Aripiprazole 2 mg tablet instead of one. 2. A review of R1's medical record revealed a medication order for Aripiprazole 2 mg tablet: Take one tablet(s) by mouth every day at bedtime. 3. A review of BH5202's staff schedule revealed E2 was scheduled during the time of the incident and provided assistance in the self-administration of medication to a resident. 4. A review of R1's MAR's record revealed E2 provided assistance in the self-administration of medication to R1. 5. In an interview, E1 acknowledged E2 provided assistance in the self-administration of medication to a resident not in compliance with the orders. 6. In an exit interview, E1 was present during the review of the inspection that covered E2 provided assistance in the self-administration of medication to a resident not in compliance with the orders.


summary: Complaint - 1/30/2024 - 6/21/2024

raw_content: An on-site investigation of complaint AZ00200597 was conducted on January 30, 2024 and the following deficiencies were cited :

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

evidence: Based on documentation review and interview, the administrator failed to ensure a resident was treated with dignity, respect, and consideration. The deficient practice posed a risk to the physical health and safety of R1.

findings: 1. A review of facility documentation revealed an incident report dated August 18, 2023 at 8:15 pm. The incident report stated, " Description of the Incident: [R1] was involved in a verbal altercation with [R1's] peers which resulted in [R1's] peers throwing hot water at [R1's] face. The client was transported by EMS to the hospital; Individual's Condition Before & After the Incident: Physically fine before the incident but became upset during the incident. [R1] was crying and in pain after the incident; Description of any Medical Services Received: EMS transported [R1] to the hospital where [R1] was treated for first degree burns to [R1's] chest." 2. In an interview, E1 and E2 reported that they removed the hot water feature from the cold/hot water dispenser next to the TV in the main living room. 3. In an interview, E1 and E2 reported the first peer who threw water on R1 used hot water and the second peer used cold water, after E1 and E2 investigated the incident. E1 and E2 reported removing the peer who threw hot water from the facility and relocating the peer who threw cold water. 4. In an interview, E1 and E2 acknowledged the administrator failed to ensure a resident was treated with dignity, respect, and consideration.

evidence: Based on documentation review and interview, the administrator failed to ensure the premises and equipment were free from a condition or situation which caused a resident to suffer physical injury. The deficient practice posed a physical health and safety risk to R1.

findings: 1. A review of facility documentation revealed an incident report dated August 18, 2023 at 8:15 pm. The incident report stated, " Description of the Incident: [R1] was involved in a verbal altercation with [R1's] peers which resulted in [R1's] peers throwing hot water at [R1's] face. The client was transported by EMS to the hospital; Individual's Condition Before & After the Incident: Physically fine before the incident but became upset during the incident. [R1] was crying and in pain after the incident; Description of any Medical Services Received: EMS transported [R1] to the hospital where [R1] was treated for first degree burns to [R1's] chest." 2. In an interview, E1 and E2 reported that they removed the hot water feature from the cold/hot water dispenser next to the TV in the main living room. 3. In an interview, E1 and E2 acknowledged the administrator failed to ensure the premises and equipment were free from a condition or situation which caused a resident to suffer physical injury.


summary: Compliance (Annual) - 6/19/2023

raw_content: Based on Arizona Revised Statutes \'a7 36-424(B) and Arizona Administrative Code R9-10-109(E), the Department may accept an accreditation report in lieu of an onsite compliance inspection during the time of the accreditation report. The licensee submitted to the Department the current accreditation report from The Joint Commission, valid from March 26, 2022 through March 25, 2025. If the health care institution's accreditation report is not valid for the entire licensure period, the department may conduct a compliance inspection of the health care institution during the time period the Department does not have a valid accreditation report for the health care institution.