summary: Complaint;Compliance (Annual) - 10/8/2024

raw_content: The following deficiencies were found during the on-site compliance inspection and investigation of complaint AZ00204778 conducted on October 8, 2024:

evidence: Based on documentation review, record review, and interview, the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery including initial training and continued competency training in fall prevention and fall recovery. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not implemented.

findings: 1. A review of facility documentation revealed a program regarding fall prevention and fall recovery was not available for review. 2. A review of E2's and E3's personnel record revealed documentation of initial training and continued competency in fall prevention and fall recovery was not available for review. 3. In an interview, E1 acknowledged the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery.

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

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

findings: 1. A review of facility documentation revealed a policy and procedure titled "R9-10-706 ORIENTATION" dated in 2024. The policy stated "The Program Director and Facility Manager shall ensure that all staff attends an orientation session within the first week of employment. Orientation shall include. A. Review of the facility's and personnel policies and procedures which include the following: 1. Child Management Techniques 2. Behavior Management Techniques 3. Review of Policies and Procedures 4. Health Care Issues and Procedures 5. Medication self-administration training from RN 6. Checking Certification in CPR and First-Aid (A website will be provided to obtain) 7. Skill related to Cultural and Ethnic Differences 8. Self-Awareness 9. Values 10. Professional Ethics..." 2. A review of E3's (hired in 2024) personnel record revealed E3 was hired as a behavioral health technician. E3's personnel record revealed documentation of E3's completed orientation was not available for review. 3. A review of E5's (hired in 2024) personnel record revealed E5 was hired as a behavioral health technician. E5's personnel record revealed documentation of E5's completed orientation was not available for review. 4. In an interview, E1 reported E3 and E5 received orientation, however the orientation was not documented. E1 acknowledged documentation of E3 and E5's orientation was not available for review. This is a repeat deficiency from an inspection conducted on April 26, 2023 and May 2, 2022.

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 documentation review, record review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of cardiopulmonary resuscitation (CPR) training and first aid training, if required for the individual according to R9-10-703(C)(1)(e), for two of five personnel sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency.

findings: 1. A review of the facility's policies and procedures revealed a policy titled "CLIENT INDEPENDENT LIVING & STAFF CERTIFICATIONS" dated in 2024. "A minimum of 1 on duty BHT staff member must possess current and valid CPR and First Aid certification. 2. A review of the facility's staffing schedule revealed E2 was the only staffing working from 2:00 pm-10:00 pm shift on October 1-4, 2024 and October 7, 2024. 3. A review of the facility's staffing schedule revealed E3 was the only staffing working from 12:00 pm-8:00 am shift on October 2, 2024 and 4, 2024. 4. A review of E2's personnel record revealed documentation of current CPR training dated November 29, 2022, from "NationalCPRFoundation". The document stated "Valid for 2 years" 5. A review of the "nationalcprfoundation.com" website revealed the following statement: "National CPR Foundation is known for providing Life-Skill Techniques for longer more lasting lives. Harness the Power of Our Online Training and Earn Your Certification Today - The Smarter Way." 6. 4. A review of E3's personnel record revealed documentation of CPR and first aid training. However, the CPR and first aid training expired on December 2023. 7. In an interview, E1 acknowledged E2's CPR was completed online, and E3's CPR and first aid training was expired.

rule: A. An administrator shall ensure that a discharge plan for a resident is: 1. Developed that: a. Identifies any specific needs of the resident after discharge, b. Is completed before discharge occurs, and c. Includes a description of the level of care that may meet the resident's assessed and anticipated needs after discharge;

evidence: Based on record review and interview, the administrator failed to ensure that a discharge plan for a resident is developed that identifies and specific needs of the resident after discharge and includes a description of the level of care that may meet the resident's assessed and anticipated needs after discharge for one of three residents sampled.

findings: 1. A review of R2's medical record revealed a document titled "Discharge Summary" dated December 30, 2023. The document stated "Discharge reason: Hospital Admission...Discharge Disposition: Moderate assistance required...Summary of care/status at discharge: Clients had trouble sleeping multiple nights and attacked staff multiple times on 12/29/23. Staff needed to restrain client multiple times and eventually gave the client a cpu [computer] to calm [R2] down finally...Discharge instructions: follow-up." The document was signed and dated by E1, however, the document did not include any specific needs of the resident after discharge and a description of the level of care that may meet the resident's assessed and anticipated needs after discharge. 2. In an interview, E1 acknowledged R2's medical record did not include include any specific needs of the resident after discharge and a description of the level of care that may meet the resident's assessed and anticipated needs after discharge.

rule: B. An administrator shall ensure that: 1. A request for participation in developing a resident's discharge plan is made to the resident or the resident's representative, 2. An opportunity for participation in developing the resident's discharge plan is provided to the resident or the resident's representative, and 3. The request in subsection (B)(1) and the opportunity in subsection (B)(2) are documented in the resident's medical record.

evidence: Based on record review and interview, the administrator failed to ensure a request for participation in developing the resident's discharge plan and an opportunity for participation in developing the resident's discharge plan was provided to the resident or the resident's representative and was documented in the resident's medical record, for one of three residents sampled. The deficient practice posed a risk if a resident's representation did not participate in goals and objectives for a resident in preparation for the patient's discharge.

findings: R9-10-101.77. "Discharge planning" means a process of establishing goals and objectives for a patient in preparation for the patient's discharge. 1. A review of R2's medical record revealed a document titled "Discharge Summary" dated December 30, 2023. The document stated "Discharge reason: Hospital Admission...Discharge Disposition: Moderate assistance required...Summary of care/status at discharge: Clients had trouble sleeping multiple nights and attacked staff multiple times on 12/29/23. Staff needed to restrain client multiple times and eventually gave the client a cpu [computer] to calm [R2] down finally...Discharge instructions: follow-up." However, the document did not include documented evidence a request for participation and an opportunity for participation were made to resident's representative. 2. In an interview, E1 acknowledged R2's medical record did not include documented evidence a request for participation and an opportunity for participation were made to resident's representative.

rule: D. An administrator shall ensure that there is a documented discharge order by a medical practitioner or behavioral health professional before a resident is discharged unless the resident leaves the behavioral health residential facility against a medical practitioner's or behavioral health professional's advice.

evidence: Based on record review and interview, the administrator failed to ensure there was a documented discharge order by a medical practitioner or behavioral health professional before a resident was discharged, unless the resident leaves the behavioral health residential facility against a medical practitioner's or behavioral health professional's advice, for one discharged resident sampled. The deficient practice posed a risk if the discharge order had not been documented by a medical practitioner or behavioral health professional.

findings: 1. A review of R2's medical record revealed a document titled "Discharge Summary" dated December 30, 2023. The document stated "Discharge reason: Hospital Admission...Discharge Disposition: Moderate assistance required...Summary of care/status at discharge: Clients had trouble sleeping multiple nights and attacked staff multiple times on 12/29/23. Staff needed to restrain client multiple times and eventually gave the client a cpu [computer] to calm [R2] down finally...Discharge instructions: follow-up." 2. A review of R2's medical record revealed no documented discharge order by a medical practitioner or behavioral professional before R2 was discharged. 3. In an interview, E1 acknowledged R2's medical record did not include a documented discharge order by a medical practitioner or behavioral health professional before R2 was discharged.

rule: G. An administrator shall ensure that a discharge summary for a resident: 2. Includes: a. The following information authenticated by a medical practitioner or a behavioral health professional: i. The resident's presenting issue and other physical health and behavioral health issues identified in the resident's treatment plan; ii. A summary of the treatment provided to the resident; iii. The resident's progress in meeting treatment goals, including treatment goals that were and were not achieved; and iv. The name, dosage, and frequency of each medication ordered for the resident by a medical practitioner at the behavioral health residential facility at the time of the resident's discharge; and b. A description of the disposition of the resident's possessions, funds, or medications brought to the behavioral health residential facility by the resident.

evidence: Based on record review and interview, the administrator failed to ensure a discharge summary for a resident included the requirements in R9-10-709(G)(2)(a)(ii-iv)(b), for one discharged resident sampled.

findings: 1. A review of R2's medical record revealed a document titled "Discharge Summary" dated December 30, 2023. The document stated "Diagnosis: F84.0...Presenting problems on admission: Autism spectrum disorder, disruptive mood dysregulation disorder, ADHD...Discharge reason: Hospital Admission...Discharge Disposition: Moderate assistance required...Summary of care/status at discharge: Clients had trouble sleeping multiple nights and attacked staff multiple times on 12/29/23. Staff needed to restrain client multiple times and eventually gave the client a cpu [computer] to calm [R2] down finally...Discharge instructions: follow-up." However, the discharge summary did not include the following: -A summary of the treatment provided to the resident; -The resident's progress in meeting treatment goals, including treatment goals that were and were not achieved; and -The name, dosage, and frequency of each medication ordered for R2 by a medical practitioner at the behavioral health residential facility at the time of R2's discharge; and -A description of the disposition of R2's possessions, funds, or medications brought to the behavioral health residential facility by R2. 2. In an interview, E1 acknowledged the missing requirements in R2's discharge summary.

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

evidence: Based on record review and interview, the administrator failed to ensure a resident's medical record contained orders, for one of three residents sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the required documentation was not in the medical record during the inspection.

findings: 1. A review of R1's medical record revealed a medication administration record (MAR) for the month of October 2024. The MAR revealed R1 received the following medications on the following dates and times: -"Olanzapine 10 mg capsule (give [R1] 1 tablet by mouth twice daily)" on October 1-8, 2024 at "AM" and October 1-7, 2024 at "PM"; -"Lithium Carbonate 300 mg (take 1 capsule by mouth twice daily)" on October 1-8, 2024 at "AM" and October 1-7, 2024 at "PM"; and -"Propranolol 10 mg (take 1 tab by mouth twice daily) on October 1-8, 2024 at "AM" and October 1-7, 2024 at "PM". 2. A review of R1's medical record revealed a document title "AFTER VISIT SUMMARY" dated March 6, 2024. The document stated "Your medication list...Lithium 300 mg capsule...Olanzapine 10 mg tablet...Propranolol 10 mg...Vitamin D3 50 mcg (2000 UT)..." The document listed R1's medications, however, the document did not contain medication orders. 3. In an interview, E1 acknowledged R1's medical record did not contain medication orders.

rule: F. An administrator shall ensure that: 1. A personnel member whose job description includes the ability to use an emergency safety response: b. Completes training required in subsection (F)(1)(a): ii. At least once every 12 months after the date the personnel member completed the initial training;

evidence: Based on interview and record review, the administrator failed to ensure a job description included a personnel member's ability to use an emergency safety response (ESR), and a personnel member completed training required in R9-10-716.F.1.a. at least once every twelve months after the personnel member completed the original training, for one of five sampled personnel members.

findings: 1. A review of R2 medical records revealed a document titled "Discharge Summary" dated December 30, 2023. The document stated "Discharge reason: Hospital Admission...Discharge Disposition: Moderate assistance required...Summary of care/status at discharge: Clients had trouble sleeping multiple nights and attacked staff multiple times on 12/29/23. Staff needed to restrain client multiple times and eventually gave the client a cpu [computer] to calm [R2] down finally..." 2. In an interview, E1 reported E6 (hired as a BHT) did not put R2 into a restraint, and E6 implemented the use of the ESR and R2 was placed into a therapeutic hold. 3. A review of the facility's policies and procedures revealed a policy titled "R9-10-706 QUALIFICATIONS OF SPECIFIC POSITIONS OR TASKS" The policy stated "BHT: Responsible for the direct care of the youth following the blueprint laid in agency's Policies and Procedures. Education: High School Diploma or at least 3 months of verifiable experience if no diploma. Experience: None needed. Skills and Knowledge: Critical thinking skills and knowledge of children whom may have a behavioral health diagnosis. The ability to be a team player and meticulous with notations, keeping records as well keeping a clean environment. A learning attitude." However, the policy did not include the ability of staff to provide crisis intervention training. 4. A review of E6's (hired as a behavioral health technician) personnel record revealed E6 had ESR training through the Crisis Prevention Institute, however, the document stated "Date of completion: 25 Apr 2022." 5. In an interview, E1 acknowledged policies and procedures did not include a job description for the ability of staff to provide crisis intervention training, and E6 did not complete training required in R9-10-716.F.1.a at least once every twelve months after E6 completed the original training.

rule: 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 b. Includes: i. A demonstration of the personnel member's skills and knowledge necessary to provide assistance in the self-administration of medication, ii. Identification of medication errors and medical emergencies related to medication that require emergency medical intervention, and iii. The process for notifying the appropriate entities when an emergency medical intervention is needed;

evidence: Based on record review and interview, the administrator failed to ensure training in the assistance in the self-administration of medication included a demonstration of the personnel member's skills and knowledge necessary to provide assistance in the self-administration of medication, identification of medication errors, and medical emergencies related to medication that required emergency medical intervention, and the process for notifying the appropriate entities when an emergency medical intervention was needed, provided by a medical practitioner or registered nurse or an individual trained by a medical practitioner or registered nurse, for two of five personnel sampled. The deficient practice posed a risk if a resident experienced a change in condition due to improper assistance in the self-administration of medication.

findings: 1. A review of E2's personnel record revealed a document titled "Staffing Training Record" dated February 3, 2024. The document stated "Dalla Homecare Intervention staff training policy is that full-time support staff members receive at least 4 hours of annual training, and full-time direct care staff members receive at least 24 hours of annual...Topic will cover: Medication self-administration training...EMPLOYEES THAT ATTENDED THE TRAINING:...E2." However, the documentation did not include: documentation the training was provided by a medical practitioner or registered nurse or an individual trained by a medical practitioner or registered nurse, training in the assistance in the self-administration of medication to include a demonstration of the personnel member's skills and knowledge necessary to provide assistance in the self-administration of medication, identification of medication errors, and medical emergencies related to medication that required emergency medical intervention, and the process for notifying the appropriate entities when an emergency medical intervention was needed. 2. A review of E3's personnel record revealed documentation of assistance in the self-administration of medication training for E3 was not available for review. 3. A review of R1's and R3's medication administration record (MAR) dated October 2024 revealed E2 and E3 provided assistance in the self-administration of medication to R1 and R3 between the dates of October 1-8, 2024. 4. In an interview, E1 acknowledged E2's and E3's personnel records did not include documentation of training in the assistance in the self-administration of medication as required.

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 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: 1. A review of R3's medical record revealed a medication order dated November 27, 2023 for "Vyvanse 40 mg capsule take 1 capsule by oral route every day in the morning." 2. A review of R3's medications revealed "Vyvanse 40 mg" was not available for review. 3. A review of R3's medication administration record (MAR) for October 2024 stated "Lisdexamfetamine [Vyvanse] 40 mg capsules take 1 capsule by mouth every morning." However, the MAR contained circled dates from October 1-8, 2024. 4. In an interview, E3 stated the circled dates meant the medication was not given. 5. In an interview, E1 reported insurance did not cover "Vyvanse 40 mg". E1 acknowledged assistance in the self-administration of medication provided R1 was not in compliance with an order.


state: AZ

facility_name: DALIA HOMECARE LLC

summary: Complaint;Compliance (Annual) - 4/26/2023

raw_content: The following deficiencies were found during the on-site compliance inspection and investigation of complaint AZ00190863 conducted on April 26, 2023:

inspection_type: Complaint;Compliance (Annual)

rule: A.R.S.§ 36-411. Residential care institutions; nursing care institutions; home health agencies; fingerprinting requirements; exemptions; definitions A. Except as provided in subsection F of this section, as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work or contracted work.

evidence: Based on record review, documentation review, and interview, a residential care institution failed to ensure an employee had a valid fingerprint clearance card, for one of three personnel members sampled. The deficient practice posed a risk if E2 was a danger to a vulnerable population.

findings: 1. A review of E2's personnel record revealed a fingerprint clearance card with an issue date of September 7, 2021, and an expiration date of September 7, 2027. 2. A review of the Arizona Department of Public Safety (DPS) fingerprint clearance card verification website revealed E2's fingerprint clearance card status was "Not Valid." 3. In a telephonic interview, the Compliance Officer and E1 spoke with O1, a representative from DPS. O1 reported E2 was issued a valid fingerprint clearance card, however, E2's fingerprint clearance became invalid after E2's fingerprint clearance card was issued. 4. In an interview, E1 acknowledged E2's fingerprint clearance card was currently invalid.

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

findings: 1. A review of E4's (hired as a BHP) personnel record revealed documentation to demonstrate E4's skills and knowledge were verified and documented was not available for review. 2. A review of E2's (hired as a BHT) personnel record revealed documentation of E2's completed orientation was not available for review. 3. A review of E3's (hired as a BHT) personnel record revealed documentation of E3's completed orientation was not available for review. 4. A review of E4's personnel record revealed documentation of E4's completed orientation was not available for review. 5. In an interview, E1 acknowledged the aforementioned documentation was not provided to the Department within two hours after a Department request.

rule: G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes: 3. Documentation of: a. The individual's qualifications, including skills and knowledge applicable to the individual's job duties;

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel members to include documentation of the individual's skills and knowledge, for one of three personnel members sampled. The deficient practice posed a risk if E4 were unable to meet the needs of the residents, the Department was unable to determine substantial compliance as the documentation was not in the personnel record during the inspection, and the documentation was not provided within two hours after a Department request.

findings: 1. A review of the facility's policies and procedures revealed a policy titled "R9-10-706 QUALIFICATIONS OF SPECIFIC POSITIONS OR TASKS" dated March 15, 2022. The policy stated "BHP: Responsible for the therapy of our youth. Clinical oversite and maintaining company compliance with state requirements. Qualifications: Professional designation, must have the contracted individual's documentation." However, the policy did not include the skills and knowledge required for a behavioral health professional. 2. A review of E4's personnel record revealed documentation to demonstrate E4's skills and knowledge were verified and documented was not available for review. 3. In an interview, E1 reported E1 had documentation of E4's skills and knowledge, however, E1 could not locate the documentation. E1 acknowledged documentation to demonstrate E4's skills and knowledge were verified and documented was not available for review.

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of the individual's completed orientation as required by policies and procedures, for three of three personnel members sampled. The deficient practice posed a risk if E2, E3, and E4 were unable to meet the needs of the residents, the Department was unable to determine substantial compliance as the documentation was not in the personnel record during the inspection, and the documentation was not provided within two hours after a Department request.

findings: 1. Arizona Administrative Code (A.A.C.) R9-10-101.155. states "Orientation" means: "the initial instruction and information provided to an individual before the individual starts work or volunteer services in a health care institution." 2. A review of the facility's policies and procedures revealed a policy titled "R9-10-706 ORIENTATION" dated March 15, 2022. The policy stated "Upon hiring, all new hire staff will need to go through our 4-hour training process before working alone. Professional test may be given to ensure that enough pertinent information has been retained. Ongoing staff meetings will take place at least, but not limited to, once every 30 days." 3. A review of E2's (hired as a BHT) personnel record revealed documentation of E2's completed orientation was not available for review. 4. A review of E3's (hired as a BHT) personnel record revealed documentation of E3's completed orientation was not available for review. 5. A review of E4's (hired as a BHP) personnel record revealed documentation of E4's completed orientation was not available for review. 6. In an interview, E1 reported E2, E3, and E4 completed orientation, however, E1 could not locate the documentation. E1 acknowledged documentation of E2's, E3's and E4's orientation was not available for review. This is a repeat citation from the previous on-site compliance inspection conducted on May 2, 2022.

rule: F. An administrator shall ensure that: 1. A personnel member whose job description includes the ability to use an emergency safety response: b. Completes training required in subsection (F)(1)(a): i. Before providing behavioral health services, and

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel member completed training in the use of an emergency safety response as required in subsection (F)(1)(a) before providing behavioral health services, for two of three personnel members sampled.

findings: 1. A review of the facility's policies and procedures revealed a job description for behavioral health technicians (BHT). However, the use of emergency safety response was not included. 2. A review of the facility's policies and procedures revealed a policy titled "R9-10-716 LEVEL SYSTEM AND DEALING WITH DIFFICULT YOUTH DEVELOPMENT" dated March 15, 2022. The policy stated "C. The Personnel Department shall ensure that all employees provide the following documents to be copied and placed in all employee personnel files within 30 days of start date of employment. 1. CPR and First Aid Certification 2. CPI training." 3. A review of E2's personnel record revealed crisis prevention training from the Crisis Prevention Institute, dated January 6, 2023. However, the emergency safety response training was not completed before E2 provided behavioral health services. 4. A review of E3's personnel record revealed crisis prevention training from the Crisis Prevention Institute, dated December 21, 2022. However, the emergency safety response training was not completed before E3 provided behavioral health services. 5. In an interview, E1 acknowledged E2 and E3 did not complete emergency safety response training before providing behavioral health services.


facility_name: FORWARD IN LIFE

summary: Complaint - 12/15/2025

raw_content: The following deficiencies were found during the on-site investigation of complaint 00150605 conducted on December 15, 2025:

inspection_type: Complaint

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

evidence: Based on documentation review and interview, the administrator failed to ensure sufficient personnel members were present on a behavioral health residential facility's premises with the qualifications, experience, skills, and knowledge necessary to ensure the health and safety of a resident. The deficient practice posed a risk as sufficient staff were not present to meet the unscheduled needs of the resident requiring continuous protective oversight.

findings: 1. A review of Department documentation revealed BH6589 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 "Report of Unusual Occurrence" (dated November 14, 2025). The report stated " ... Time: 6:58am … [R1] ran away from the house. Left out porch sliding door and out back gate. … Informed to the police but [R1] get back to group home at 7:25am.” 3. A review of facility documentation revealed a document titled "Report of Unauthorized Absence/AWOL" (dated November 14, 2025). The report stated " ... Time: 6:58am … All cts [sic] were getting ready for school and staff was assisting a peer. Another peer reported that [R1] had just left with another peer out sliding door of porch. … Staff searched immediate vicinity of home and was unable to locate. Staff notified Admin. Admin arrived at the facility within 2 min of staff call and also searched surrounding neighborhood by vehicle. Staff contacted Phenix police 911.” 4. A review of facility documentation revealed a document titled "INCIDENT, ACCIDENT OR DEATH REPORT" (dated November 15, 2025). The report stated " ... Date of Incident: 11/14/2025 Time of Incident: 06:58 AM. … [R1] had been getting ready for school. At 658am a peer reported to staff (staff had been assisting another ct in [another resident’s] room) that Ct and a 2nd peer had AWOL’d from home. … Staff immediately looked to cts inside and outside of home. Staff contacted admin. Admin was already in route to facility, and got to facility within 2 min. Admin then looked to cts via vehicle in surrounding neighborhood, but was unable to locate. Staff called police 911 to report. [R1] and peer returned to the facility at 728am. …” 5. A review of facility documentation revealed a daily staffing schedule for November 2025. The staffing schedule revealed one personnel member was scheduled to work on the date and time of R1’s 6:58 AM unauthorized absence. 6. In an interview, E2 reported only 1 personnel member was present on the facility’s premises when R1 left the facility on November 15, 2025, at 6:58 AM. E2 reported E2 was just arriving at the facility when R1 left the facility. 7. A review of facility documentation revealed a document titled "Report of Unusual Occurrence" (dated in November 14, 2025). The report stated " ... Time: 5:59pm … Upon returning home, [R1] got out of van and ran off thru complex field with 2 peers @ 559pm. Staff called out for [R1], but [R1] continued to run away. Staff then searched Home vicinity via van but was unable to locate [R1]. 911 was called at 6:07pm. … [R1] returned at 647pm to facility. 8. A review of facility documentation revealed a document titled "Report of Unauthorized Absence/AWOL" (dated in November 14, 2025). The report stated " ... Time: 5:59pm… Upon returning [R1] got out of van and ran off with 2 peers thru the complex field at 559pm staff called out to [R1], [R1] continued to run. Staff immediately got back into van to check surrounding neighborhood, but was unable to locate cts [sic]. Staff then contacted Phoenix PD @ 6:07pm…. This was the 2nd AWOL today.” 9. A review of facility documentation revealed a document titled "INCIDENT, ACCIDENT OR DEATH REPORT" (dated in November 15, 2025). The report stated " ... Date of Incident: 11/14/2025 Time of Incident: 05:59 PM. … [R1] got out of van and ran off thru complex field with 2 peers at 559p. Staff called out to [R1], and [R1] continued to run. Staff immediately got back into vehicle to search neighborhood for [R1], but was unable to locate. Staff called 911 at 6:07pm to report and assist with finding [R1].” 10. A review of facility documentation revealed a daily staffing schedule for November 2025. The staffing schedule revealed two personnel members were scheduled to work on the date and time of R1’s 5:59 PM unauthorized absence. 11. In an interview, E2 reported E1, E2, and the residents were returning from a trip to the park. E2 reported R1 ran out of the van while E2 tried to go after R1, but R1 continued to run away. E2 reported R1 ran very fast. 12. In a joint exit interview, the findings were reviewed with E1 and E2, and no additional comments, statements, or documentation were provided regarding the findings.

rule: R9-10-716.A.2.b. Behavioral Health Services A. An administrator shall ensure that: 2. If a behavioral health residential facility is licensed to provide behavioral health services to individuals whose behavioral health issue limits the individuals' ability to function independently, a resident admitted to the behavioral health residential facility with limited ability to function independently receives: b. Continuous protective oversight;

evidence: Based on documentation review and interview, the administrator failed to ensure, 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.


summary: Complaint - 11/3/2025

raw_content: No deficiencies were found during the on-site  investigation of complaint 00149558 conducted on November 3, 2025.


summary: Compliance (Annual) - 9/12/2025

raw_content: No deficiencies were found during the on-site compliance inspection conducted on September 12, 2025.

inspection_type: Compliance (Annual)


summary: Complaint - 1/3/2025

raw_content: An on-site investigation of complaint AZ00215689 was conducted on January 3, 2025 and no deficiencies were cited.


summary: Complaint;Compliance (Annual) - 7/31/2024

raw_content: The following deficiency was found during the on-site compliance inspection and investigation of complaint AZ00212823 conducted on July 31, 2024:

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

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a treatment plan included the behavioral health services to be provided to the resident, for two of two residents sampled.

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. R9-10-101.135. "Medication administration" means restricting a patient's access to the patient's medication and providing the medication to the patient or applying the medication to the patient's body, as ordered by a medical practitioner. 1. A review of facility documentation revealed policies and procedures to cover assistance in the self-administration of medication and medication administration. 2. A review of R1's medical record revealed a treatment plan (dated in 2024). However, R1's treatment plan did not include whether assistance in the self-administration of medication or medication administration was to be provided to R1. 3. A review of R2's medical record revealed a treatment plan (dated in 2024). However, R2's treatment plan did not include whether assistance in the self-administration of medication or medication administration was to be provided to R2. 4. In an interview, E5 reported E5 puts medication in a cup and then gives the cup to the resident. 5. In an interview, E5 reported the level of medication services (self-administration, assistance in the self-administration of medication, or medication administration) to be provided to a resident depended on the resident. 6. In an interview, E5 acknowledged R1's and R2's treatment plans did not include the behavioral health services to be provided to the resident.


summary: Complaint - 11/28/2023

raw_content: An on-site investigation of complaint AZ00203359 was conducted on November 28, 2023 and the following deficiencies were cited :

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

evidence: Based on documentation review and interview, the administrator failed to provide written notification to the Department of a resident's self-injury, within two working days after the resident inflicted a self-injury requiring immediate intervention by an emergency medical services provider. The deficient practice posed a risk as the Department was unable to determine if there was an immediate health and safety risk to other residents of the facility.

findings: 1. A review of facility documentation revealed a document titled "Report of Unusual Occurrence" (dated November 16, 2023 at 7:35PM). The document stated "Ct had been in bathroom to complete shower approx. 10 min, @ 7:35PM Ct called staff name opened bathroom door stating 'I think I may need to go to hospital.' Approx 3in cut at R thigh above knee was noted. Immediate pressure was applied and EMS contacted ... transported to [hospital]. ... [R1] broke a plastic mirror and used small piece to cut self." However, documentation to demonstrate BH6589 provided written notification to the Department within two working days of a resident's self-injury requiring immediate intervention by an emergency medical services provider was not available for review. 2. A review of facility documentation revealed a document titled "Report of Unusual Occurrence" (dated November 19, 2023 at 5:30PM). The document stated "[R1] asked to take a shower. I gave [R1] hygiene bucket and checked to make sure there were no sharp objects in it. I check bathroom as well. Checked and said [R1] was ok. [R1] came out leg bloody and I applied pressure and called 911. ... transp [sic] to hospital." 3. A review of facility documentation revealed a document titled "Arizona Health Care Cost Containment System INCIDENT, ACCIDENT OR DEATH REPORT" (dated November 20, 2023) for an incident dated November 19, 2023. The document stated "[R1] had requested to take shower. Staff had checked hygiene box and bathroom for sharp objects and non were found. After using shower, [R1] reported to staff [R1] had cut [themselves] with object [R1] was hiding on person." However, documentation to demonstrate BH6589 provided written notification to the Department within two working days of a resident's self-injury requiring immediate intervention by an emergency medical services provider was not available for review. 4. A review of Department documentation revealed documentation to demonstrate BH6589 provided written notification to the Department of R1's self-injuries were not available for review. 5. In an interview, E2 reported to be unaware of the requirement, and reported written notification to the Department of R1's self-injuries were not provided. 6. In an interview, E2 acknowledged written notification to the Department of R1's self-injuries were not provided to the Department.

rule: A. An administrator shall ensure that: 1. A resident is admitted based upon: a. The resident's primary condition for which the resident is admitted to the behavioral health residential facility being a behavioral health issue, and

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a resident was admitted based upon the resident's primary condition being a behavioral health issue, for one resident sampled whose primary condition was not a behavioral health issue. The deficient practice posed a risk as R3 required services from a Behavior Supported DD Group Home.

findings: R9-10-101.32. "Behavioral health issue" means an individual's condition related to a mental disorder, a personality disorder, substance abuse, or a significant psychological or behavioral response to an identifiable stressor or stressors. 1. A review of Department documentation revealed BH6589 was licensed as a Behavioral Health Residential Facility for children. 2. A review of facility documentation revealed a scope of services titled "Scope of Services- Provision of Behavioral Health Services" (dated November 20, 2020). The scope of services stated "11. This facility will not accept or retain residents that have a primary diagnosis of intellectual disability, primary medical needs (that are not temporary), or severe brain damage, or have a recent history (within the past 12 months) of sexual offenses and violent offenses towards staff and/or residents in previous placements, or have cognitive deficits that severely limit the resident's ability to benefit from the treatment services we provide." 3. A review of R3's medical record revealed a document with a header "DDD-2089A FORFF (3-12)" (dated March 28, 2022). The document stated "Member was diagnosed with Global development delays- speech at age two. At age five [R3] was diagnosed with Opposition Defiance Disorder, Autism, and Dyspraxia." 4. A review of the Arizona Department of Economic Security website revealed "DDD-2089A FORFF" was a document from the Division of Developmental Disabilities titled "DDD PERSON CENTERED SERVICE PLAN." 5. A review of R3's medical record revealed a document titled "Initial Assessment Report and Treatment Plan" (dated April 4, 2023) from "Thrive Autism Services." The document stated "Diagnosis: Autism Spectrum Disorder F84.0." 6. A review of R3's medical record revealed a document titled "Resident Health History" (dated in 2023). The document stated "Medical Diagnosis: autism" as the first diagnosis. 7. A review of R3's medical record revealed a behavioral health assessment (dated in 2023). The assessment stated "This client has suffered with chronic features of Autism Spectrum Disorder, behavioral health disturbances and intellectual disturbances since birth ... Diagnosis F84.0 Autism Spectrum Disorder" as the first diagnosis. 8. A review of R3's medical record revealed documents titled "Progress Note (dated July 27, 2023; August 10, 2023; and October 2, 2023). The documents stated "Diagnosis F84.0 Autism Spectrum Disorder" as the first diagnosis, and " ...6. Provide autism specific therapy to address social deficiencies, reduced level of empathy and emotional dysregulation." 9. A review of R3's medical record revealed an initial treatment plan. The treatment plan stated "Diagnosis F84.0 Autism Spectrum Disorder" as the first diagnosis and "The client's discharge plan is to be admitted to a DDD group home when [R3] completes [R3's] treatment goals successfully. ... Autism specific therapy to address social deficiencies, reduced level of empathy and emotional dysregulation." 10. A review of R3's medical record revealed an updated treatment plan (dated October 22, 2023). The treatment plan stated "Diagnosis F84.0 Autism Spectrum Disorder" as the first diagnosis and " 08/07/2023 - Autism Spectrum Disorder was originally the primary diagnosis. Autism is a neurodevelopmental disorder rather than a mental illness. Disruptive Mood Dysregulation Disorder is now listed as [R3's] primary diagnosis. ... The client's discharge plan is to be admitted to a DDD group home when [R3] completes [R3's] treatment goals successfully. ... Autism specific therapy to address social deficiencies, reduced level of empathy and emotional dysregulation." 11. A review of R3's (admitted in July 2023) medical record revealed a document titled "Consultation Note" (dated October 23, 2023). The document stated " ... [E2] reported the house is working on getting ABA therapy in place for [R3]." 12. A review of R3's medical record revealed a document titled "Consultation Note" (dated November 16, 2023). The document stated "Diagnosis F84.0 Autism Spectrum Disorder" as the first diagnosis and " ... working towards the goal of client moving down to DDD home once ABA services have started ... Client identified that [R3] asked for crisis to be called one of the times as [R3] felt [R3] needed to talk to another person for support. [O1] reported that client has decreased [R3's] calls to crisis 99% ... [O1] clarified that these types of calls are typical of ASD ... team can further discuss transitioning to DDD home." 13. In an interview, E2 reported R3's diagnosis was changed. E2 reported R3 was admitted to BH6589 for behaviors in order to be stable in a Behavior Supported DD Group Home. E2 reported Behavior Supported DD Group Homes would not admit R3. 14. In an interview, the findings were reviewed with E2 and no additional comments or statements were provided regarding the findings. This is a repeat deficiency from the on-site compliance inspection and complaint investigation conducted on June 26, 2023.


summary: Complaint;Compliance (Annual) - 6/26/2023

raw_content: The following deficiencies were found during the compliance inspection and investigation of complaints AZ00196463 and AZ00196798 conducted on June 26, 2023:

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

evidence: Based on documentation review, record review, and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery.

findings: 1. A review of the facility's policies and procedures revealed a policy titled "Orientation and In-Service Training" (date unavailable). The policy stated "4. In-service Fall Prevention and Recovery Training will be provided upon hire and at least every 12 months thereafter." 2. A review of E1's and E2's personnel records revealed initial training (dated in February 2022). However, documentation of continued competency training in fall prevention and fall recovery, at least every twelve months, was not available for review. 3. A review of E3's personnel record revealed documentation of initial training and continued competency training in fall prevention and fall recovery was not available for review. 4. In an interview, E5 reported E5 assumed E1 had continued competency training in fall prevention and fall recovery. 5. In an interview, E5 acknowledged E1's and E2's documentation of continued competency training regarding fall prevention and fall recovery was not available for review. 6. In an interview, E5 acknowledged E3's documentation of initial training and continued competency training regarding fall prevention and fall recovery was not available for review

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 seven 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 the facility's policies and procedures reveled a policy titled "Employees and Volunteers Qualifications" (dated November 20, 2020). The policy stated " ... The hiring person or administrator will ensure, check and document that the employee or volunteer providing physical health services or behavioral health services have the required skills and knowledge before providing any services." 2. A review of E2's personnel record revealed E2 was hired as the behavioral health professional. However, documentation to demonstrate E2's skills and knowledge were verified and documented was not available for review. 3. A review of E3's personnel record revealed E3 was hired as the registered nurse. However, documentation to demonstrate E3's skills and knowledge were verified and documented was not available for review. 4. In an interview, E5 acknowledged documentation to demonstrate E2's and E3's skills and knowledge were verified was not available for review. This is a repeat deficiency from the on-site compliance inspection conducted on April 25, 2022 and the off-site documentation review completed on May 3, 2022

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

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of the individual's completed orientation as required by policies and procedures, for two of seven personnel records sampled. The deficient practice posed a risk if personnel members were unable to meet a resident's needs.

findings: R9-10-101.153. "Orientation" means the initial instruction and information provided to an individual before the individual starts work or volunteer services in a health care institution. 1. A review of facility documentation revealed a policy and procedure titled "Orientation and In-Service Training" (dated November 20, 2020). The policy stated " ... 1. Each personnel member, employee, volunteer, or student receives orientation before providing behavioral health services or physical health services to a resident. ... New employee orientation is required to be completed by all new employees, personnel members, volunteers, and students before starting to provide any services to the residents ..." 2. A review of E2's personnel record revealed E2 was hired as the behavioral health professional. However, E2's personnel record revealed documentation of E2's completed orientation was not available for review. 3. In an interview, E5 reported E5 was sure E2 completed orientation. 4. A review of E3's personnel record revealed E3 was hired as the registered nurse. However, E3's personnel record revealed documentation of E3's completed orientation was not available for review. 5. In an interview, E5 acknowledged E2's and E3's personnel records were not maintained to include documentation of the individual's completed orientation. This is a repeat deficiency from the on-site compliance inspection conducted on April 25, 2022 and the off-site documentation review completed on May 3, 2022.

rule: G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes: 3. Documentation of: e. The individual's compliance with requirements in A.R.S. §§ 36-411, 36-411.01, and 36-425.03, as applicable;

evidence: Based on record review and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of compliance with the requirements in A.R.S. \'a7 36-425.03(A)(E)(G), for three of seven personnel records sampled. The deficient practice posed a risk if E6 was a danger to a vulnerable population.

findings: A.R.S. \'a7 36-425.03(A) states "Except as provided in subsections B, C and D of this section, children's behavioral health program personnel, including volunteers, shall submit the form prescribed in subsection E of this section to the employer and shall have a valid fingerprint clearance card issued pursuant to title 41, chapter 12, article 3.1 or, within seven working days after employment or beginning volunteer work, shall apply for a fingerprint clearance card." A.R.S. \'a7 36-425.03(E) states "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." A.R.S. \'a7 36-425.03(G) states "Employers of children's behavioral health program personnel shall make documented, good faith efforts to contact previous employers of children's behavioral health program personnel to obtain information or recommendations that may be relevant to an individual's fitness for employment in a children's behavioral health program." 1. A review of E2's (hired in 2022) personnel record revealed E2 was the behavioral health professional. E2's personnel record revealed a valid fingerprint clearance card. However, documentation of compliance with A.R.S. \'a7 36-425.03(G) was not available for review. 2. In an interview, E5 reported E2's previous employers were contacted but not documented. E5 acknowledged E2's documentation of compliance with A.R.S. \'a7 36-425.03(G) was not available for review. 3. A review of E3's (hired in 2022) personnel record revealed E3 was hired as the registered nurse. E3's personnel record revealed a valid fingerprint clearance card. However, documentation of compliance with A.R.S. \'a7 36-425.03(E) was not available for review. 4. In an interview, E5 reported E5 did not know if E3 had documentation of compliance with A.R.S. \'a7 36-425.03(E). E5 acknowledged E3's documentation of compliance with A.R.S. \'a7 36-425.03(E) was not available for review. 5. A review of E6's (hired in 2023) personnel record revealed E6 was hired as a behavioral health technician. E6's personnel record revealed a fingerprint clearance card (issued February 8, 2023). 6. A review of the AZDPS fingerprint clearance card status request website (https://psp.azdps.gov/services/cardStatusRequest), conducted on June 26, 2023, revealed the fingerprint clearance card status for E6 was "invalid." 7. In an interview, E5 reported to be unaware of E6's fingerprint clearance card status. 8. In an interview, E5 acknowledged E6 did not have valid fingerprint clearance card issued pursuant to title 41, chapter 12, article 3.1. This is a repeat deficiency from the on-site compliance inspection conducted on April 25, 2022 and the off-site documentation review completed on May 3, 2022.

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a resident was admitted based upon the resident's primary condition being a behavioral health issue, for one resident sampled who's primary condition was not a behavioral health issue. The deficient practice posed a risk as R1 required services from a Behavior Supported DD Group Home.

findings: R9-10-101.32. "Behavioral health issue" means an individual's condition related to a mental disorder, a personality disorder, substance abuse, or a significant psychological or behavioral response to an identifiable stressor or stressors. 1. A review of Department documentation revealed BH6589 was licensed as a Behavioral Health Residential Facility. 2. A review of facility documentation revealed a scope of services titled "Scope of Services - Provision of Behavioral Health Services" (dated November 20, 2020). The scope of services stated "11. This facility will not accept or retain residents that have a primary diagnosis of intellectual disability, primary medical needs (that are not temporary), or severe brain damage, or have a recent history (within the past 12 months) of sexual offenses and violent offenses towards staff and/or residents in previous placements, or have cognitive deficits that severely limit the resident's ability to benefit from the treatment services we provide." 3. A review of R1's medical record revealed a behavioral health assessment (dated in 2023). The assessment stated "Diagnosis F84.0 Autism Spectrum Disorder" as the first diagnosis. However, documentation of a behavioral health issue as a primary condition was not available for review. 4. A review of R1's medical record revealed a document titled "Psychological Evaluation" (dated in 2019). The document stated "The reason for this referral: [R1's] team ([parent], AZCA, DCS, Sonora, and Aurora) requested that the client be evaluated due to the child's continuous behaviors (defiance, aggressive verbal outbursts, challenging behaviors, verbalizes passive suicidal ideation, throwing objects, and danger to others. The team requested for [R1] to be assessed for Autism. [R1] lacks social skills. [R1] struggles with understanding boundaries (stranger danger). ... DIAGNOSIS: F84.0 (299.00) Autism Spectrum Disorder (Level 3) 314.00 (F90.0) Attention Deficit Hyperactivity Disorder ... scores on administered assessments and behavioral observations during testing and interview, suggested [R1] is a child with Autism Spectrum Disorder and Posttraumatic Stress Disorder." 5. A review of R1's medical record revealed a treatment plan (dated in 2023). The treatment plan stated "Diagnosis F84.0 Autism Spectrum Disorder" at the first diagnosis. 6. A review of R1's medical record revealed a document titled "Progress Note" (dated in 2023) from Intermountain Centers. The document stated "Individuals Present ... Others Present: ...[O1] (DDD) ... Goals and Objectives Addressed Today Objective Today Client will decrease [R1's] anger and aggressiveness by using [R1's] coping skills. Intervention Today DDD, Family, Intermountain ... Assessment/Diagnosis F84.0 Autistic disorder." 7. In an interview, E5 reported R1's presenting issue was not for autism. However, E5 was unable to report R1's presenting behavioral health issue. 8. In an interview, the findings were reviewed with E5 and no additional comments or statements were provided regarding the findings.


facility_name: DEVEREUX ARIZONA - BROADWAY CAMPUS

summary: Complaint - 11/18/2025

raw_content: An on-site investigation of complaints 00149783 and 00150161 was conducted on November 18, 2025, and the following deficiency was cited:

rule: R9-10-718.B.3.a-b. Medication Services 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 b. Is documented in the resident's medical record.

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure medication administration was provided to a resident in compliance with an order, for one of five residents sampled. The deficient practice posed a risk if R2 experienced a change in condition due to improper medication administration, and the repeated violation shows a pattern of non-compliance to ensure the health and safety of residents.

findings: 1. A review of facility documentation revealed a scope of services titled “Program Model: Assessment and Intervention Center (AIC)” (dated October 2024). However, the scope of services did not include whether assistance in the self-administration of medication or medication administration was provided. 2. A review of facility documentation revealed a policy and procedure titled "Medical Services, Medication Administration and Training" (dated October 28, 2022). The policy and procedure stated " ... III. Definition(s) I. Medication Administration: Securing the patients medication and providing the medication to the patient or applying the medication to the patient’s body as ordered by a medical practitioner. II. Assistance in the Self Administration of Medication: 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.” However, the policy and procedure did not include assistance in the self-administration of medication or medication administration. 3. A review of facility documentation revealed a policy and procedure titled “Medication Procedure for BHRF Programs" (dated March 27, 2024). The policy and procedure stated " ... Devereux Arizona will ensure that the practice of enrolled individual’s administration and self-administration of medications is performed in an accurate and clinically sound manner at the BHRF facility. … E. Administration of Medication 1. Administration of Medication includes: a. The BHRF Individual reports to the trained BHRF staff for medication administration. b. BHRF staff verifies the Individual’s identity by checking at least two identifiers prior to administering medication. c. BHRF staff open the medication container and provides the prescribed dosage to the BHRF Individual. d. BHRF staff verify that the BHRF Individual takes the medication in accordance with the 5 Rights of Medication Administration.” However, the policy and procedure did not include assistance in the self-administration of medication. 4. A review of R2's medical record revealed a treatment plan. The treatment plan stated “…Medication Monitoring will be provided one to ten times per month for the duration of treatment.” However, R2's treatment plan did not include whether medication administration would be provided to R2 by E3. 5. A review of R2’s medical record revealed a medication order (dated September 17, 2025) for “… sertraline HCL (sertraline HCL) 25 MG, 1 mg by mouth Twice A Day.” 6. A review of R2's medical record revealed a document titled “Medical Event Documentation” (dated October 17, 2025). The document stated “… [R2] was not administered [R2’s] Sertraline 25 MG take one tablet by mouth twice a day. … Medication Event Occurrence Date Range Start Date: 10/16/2025, End Date: 10/16/2025.” 7. A review of R2’s medical record revealed a MAR for October 2025. The MAR revealed “Sertraline” was not documented as administered on October 16, 2025, for the evening. The MAR stated “10-16 Sertraline 25mg, omitted, not given.” 8. In a joint exit interview, the findings were reviewed with E1(telephonically), E2 (telephonically), E3, E4, E5, and E6, and no additional comments or statements were provided regarding the findings. This Rule was cited during the on-site complaint investigation conducted on November 4, 2025.


summary: Complaint - 11/4/2025

raw_content:
An on-site investigation of complaints 00105664, 00116595, 00122139, 00122996, 00136046, and 00148123
was conducted on November 4, 2025, and the following deficiencies were cited:

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

evidence: Based on record review, documentation review, and interview, the administrator failed to ensure a treatment plan completed by a behavioral health technician (BHT) was reviewed and signed by a behavioral health professional (BHP) within 24 hours after the completion of the treatment plan, for three of six residents sampled. The deficient practice posed a risk as the treatment plan was reviewed and approved by a behavioral health professional who was not certified or licensed to provide the behavioral health services needed by the resident.

findings: Arizona Revised Statute (A.R.S.) § 32-2091(3) "Behavior analysis" means the design, implementation and evaluation of systematic environmental modifications by a behavior analyst to produce socially significant improvements in human behavior based on the principles of behavior identified through the experimental analysis of behavior. Behavior analysis does not include cognitive therapies or psychological testing, neuropsychology, psychotherapy, sex therapy, psychoanalysis, hypnotherapy and long-term counseling as treatment modalities. A.R.S. § 32-2091(5) "Behavior analyst" means a person who is licensed pursuant to this article to practice behavior analysis A.R.S. § 32-3251(9) "Practice of behavioral health" means the practice of marriage and family therapy, practice of professional counseling, practice of social work and practice of addiction counseling pursuant to this chapter. A.R.S. § 36-401(11) "Behavioral health services" means services that pertain to mental health and substance use disorders and that are either: (a) Performed by or under the supervision of a professional who is licensed pursuant to title 32 and whose scope of practice allows the professional to provide these services. (b) Performed on behalf of patients by behavioral health staff as prescribed by rule. R9-10-101(35) “Behavioral health professional” means the following licensed professionals that provide services specifically within the scope of practices defined by their profession: a. An individual licensed under A.R.S. Title 32, Chapter 33, whose scope of practice allows the individual to: i. Independently engage in the practice of behavioral health, as defined in A.R.S. § 32-3251; or ii. Except for a licensed substance abuse technician, engage in the practice of behavioral health, as defined in A.R.S. § 32-3251, under direct supervision as defined in A.A.C. R4-6- 101; b. A psychiatrist as defined in A.R.S. § 36-501; c. A psychologist as defined in A.R.S. § 32-2061; d. A physician; e. A behavior analyst as defined in A.R.S. § 32-2091; or f. A registered nurse practitioner licensed as an adult psychiatric and mental health nurse; g. A clinical nurse specialist as described in A.R.S. § 32-1601; or h. Psychiatric physician assistant 1. A review of R3’s medical record revealed a treatment plan. The treatment plan was completed by a BHT, and reviewed and signed by E14, “BCBA [Board Certified Behavior Analyst], BHP, Clinical Program Manager, LBA, MA.” However, the treatment plan was not reviewed and signed by a BHP within 24 hours after the completion of the treatment plan. 2. A review of R4’s medical record revealed a treatment plan. The treatment plan was completed by a behavior specialist master's level, and reviewed and signed by E14, “BCBA [Board Certified Behavior Analyst], BHP, Clinical Program Manager, LBA, MA.” However, the treatment plan was not reviewed and signed by a BHP within 24 hours after the completion of the treatment plan. 3. A review of R5’s medical record revealed a treatment plan. The treatment plan was completed by a behavior specialist master's level, and reviewed and signed by E14, “BCBA [Board Certified Behavior Analyst], BHP, Clinical Program Manager, LBA, MA.” However, the treatment plan was not reviewed and signed by a BHP within 24 hours after the completion of the treatment plan. 4. In an interview, E1 reported E14 was a licensed behavioral analyst. 5. A review of the Arizona Board of Psychologist Examiners website revealed E14 was licensed as a behavior analyst. 6. In an exit interview, the findings were reviewed with E1, E2, E3, and E4 (telephonically), 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 medication administration was provided to a resident in compliance with an order. The deficient practice posed a risk if R2 and R3 experienced a change in condition due to improper medication administration.

findings: 1. A review of facility documentation revealed a scope of services titled “Program Description Devereux Assessment and Intervention (dated October 2024). However, the scope of services did not include whether assistance in the self-administration of medication or medication administration was provided. 2. In an interview, E1 reported assistance in the self-administration of medication was provided. E1 later reported BHTs provide medication administration as BHTs punch out the medications from the pharmacy-provided multi-dose packaging, place them into a cup, and give to residents. 3. A review of facility documentation revealed a policy and procedure titled "Medical Services, Medication Administration and Training" (dated October 28, 2022). The policy and procedure stated " ... III. Definition(s) I. Medication Administration: Securing the patients medication and providing the medication to the patient or applying the medication to the patient’s body as ordered by a medical practitioner. II. Assistance in the Self Administration of Medication: 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. However, the policy and procedure did not include assistance in the self-administration of medication or medication administration. 4. A review of facility documentation revealed a policy and procedure titled “Medication Procedure for BHRF Programs" (dated March 27, 2024). The policy and procedure stated " ... Devereux Arizona will ensure that the practice of enrolled individual’s administration and self-administration of medications is performed in an accurate and clinically sound manner at the BHRF facility. … E. Administration of Medication 1. Administration of Medication includes: a. The BHRF Individual reports to the trained BHRF staff for medication administration. b. BHRF staff verifies the Individual’s identity by checking at least two identifiers prior to administering medication. c. BHRF staff open the medication container and provides the prescribed dosage to the BHRF Individual. d. BHRF staff verify that the BHRF Individual takes the medication in accordance with the 5 Rights of Medication Administration.” However, the policy and procedure did not include assistance in the self-administration of medication. 5. A review of R2's medical record revealed a treatment plan. The treatment plan stated “…Medication Monitoring 1-4x month.” 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. 6. A review of R2’s medical record revealed a medication order (dated January 28, 2025) for “Clonidine HCL 0.1 mg Oral Tablet … 0.5 Tablet, BID - Twice a Day.” 7. A review of R2's medical record revealed a document titled “Medical Event Documentation” (dated February 9, 2025). The document stated “… Individual [R2] received an extra dose of Clonidine 0.1mg. Individual [R2] is supposed to take half a tablet by mouth 3 times a day … Staff member failed to follow medical protocol and gave extra half a dose to the individual” and “The staff member followed medical directions to not give the noon dose.” 8. A review of R2’s medical record revealed a MAR for February 2025. The MAR revealed a dose count for “Clonidine” of 1 tablet on February 9, 2025, in the morning. 9. A review of R3's medical record revealed a treatment plan. However, R3's treatment plan did not include whether medication administration or assistance in the self-administration of medication was to be provided to R3. 10. A review of R3’s medical record revealed a medication order (dated April 22, 2025) for “Chlorpromazine HCL 25 mg Oral Tablet … 1 Tablet, BID – Twice a Day” and “Chlorpromazine HCL 50 mg Oral Tablet … 1 Tablet, QHS – At Bedtime.” 11. A review of R3’s medical record revealed a medication order (dated May 14, 2025) for “D/C Chlorpromazine HCL 25 g [sic] q2pm.” 12. A review of R3's medical record revealed a document titled “Medical Event Documentation” (dated May 16, 2025). The document stated “… Individual was administered a discontinued 2pm Medication … Individual is scheduled to take 1 tablet by mouth of Chlorpromazine 25mg daily in the morning as of 5/15/2025. Prior to 5/1525 [R3] was scheduled to take 1 tablet of Chlorpromazine 25mg twice daily by mouth once in the morning and 2pm.” 13. A review of R3’s medical record revealed a MAR for May 2025. The MAR revealed R3 was administered “Chlorpromazine 25mg” on May 16, 2025, at 2:00PM. 14. A review of R3's medical record revealed a document titled “Medical Event Documentation” (dated May 23, 2025). The document stated “… [R3] was administered incorrect medication/dose. [R3] was given Chlorpromazine 50mg vs Chlorpromazine 25 mg.” 15. A review of R3’s medical record revealed a MAR for May 2025. The MAR revealed a medication count for “Chlorpromazine 25mg” of 9 tablets on May 22, 2025, in the morning and 7 tablets on May 23, 2025, in the morning. The MAR stated “… Count off by 2 … 5/22/25 7:58 Chlorpromazine 25 given two to equal 50mg gave, nd [sic] two 25 mg at bedtime … 5/23/25 8:00am Chlorpromazine 25 given 50mg wrong dosage given.” 16. A review of R3's medical record revealed a document titled “Medical Event Documentation” (dated May 26, 2025). The document stated “… Staff [R10] administered Chlorpromazine 50mg tablets instead of Chlorpromazine 25mg tablets. … [R3] was to receive Chlorpromazine 50mg at bedtime. Staff [R10] administered Chlorpromazine 25mg during bedtime medication pass.” 17. A review of R3’s medical record revealed a MAR for May 2025. The MAR revealed a medication count for “Chlorpromazine 50mg” of 4 tablets on May 25, 2025, at bedtime and 4 tablets on May 26, 2025, at bedtime. The MAR stated “… 5/27/25 11:07 Chlorpromazine 50mg give the 25 mg med count is off.” 18. A review of R4's medical record revealed a treatment plan. However, R4's treatment plan did not include whether medication administration or assistance in the self-administration of medication was to be provided to R4. 19. A review of R4’s medical record revealed a medication order (dated December 17, 2024) for “Metoprolol tartrate 25mg Take 1 tablet by mouth every morning” and “Metoprolol 25mg Take 2 tablet by mouth at bedtime.” 20. A review of R4's medical record revealed a document titled “Medical Event Documentation” (dated December 28, 2024). The document stated “… On 12/28/2024 at 8:13am Individual [R4] was given an incorrect dose of Metoprolol 25mg by mouth by a Devereux staff member. … On 12/28/2024 Individual[R4] was given 2 tablets …” and “Nurse was notified and state further instructions for Individual [R4] are [R4] will only take 1 table of Metoprolol 25mg by mouth in the evening.” 21. A review of R4’s medical record revealed a MAR for December 2024. The MAR revealed a medication count for “Metoprolol” of 21 tablets on December 28, 2024, and 19 tablets on December 29, 2024. The MAR stated “… 12/28 … Metoprolol … Per nurse gave 1 from AM Pack.” 22. In an interview, E1 stated the medication errors were “staff errors.” 23. In an exit interview, the findings were reviewed with E1, E2, E3, and E4 (telephonically), and no additional comments, statements, or documentation were provided regarding the findings.


summary: Complaint - 1/7/2025

raw_content: An on-site investigation of complaint AZ00218037 was conducted on January 7, 2025, and the following deficiency was cited :

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 b. Is documented in the resident's medical record.

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 and was documented in the resident's medical record, for four of four resident records sampled. The deficient practice posed a risk to the health and safety of residents if residents did not receive their required medication and a medication error occurred.

findings: 1. A review of R1's medical record revealed a medication administration record (MAR) dated in August 2024. The MAR stated, "Buspirone HCL 7.5 MG Tablets... take 2 tablet by mouth daily for anxiety." However, on August 10, 2024, the MAR was blank as the medication was not taken. The back of the MAR included a section for personnel to make notes which was titled "Medication Not Administered (Refused/Missed/Extra/AWOL)," however personnel did not fill out the section for the August 10, 2024. 2. A review of R2's medical record revealed a MAR dated in July 2024. The MAR stated, "Guanfacine 2 MG... take one tablet by mouth 2 times a day at [7:00 AM and 4:00 PM]." However, from July 16, 2024, through July 26, 2024, the MAR revealed the medication was taken at 8:30 AM on July 16, 2024, 8:11 AM on July 17, 2024, 7:56 AM on July 18, 2024, and an average time in between 8:00 AM through 8:30 AM up until July 26, 2024. 3. A review of R2's medical record revealed a MAR dated in August 2024. The MAR stated, "Cetirizine 10 MG... take 1 tablet by mouth every morning as needed." However, the MAR revealed the medication was given on August 21, 2024, at 4:08 PM. The medication order stated it needed to be taken in the morning as needed. 4. A review of the facility's policies and procedures revealed a policy and procedure titled "Medication Procedure for BHRF Programs." The policy and procedure stated "G. Medication Administration Record (MAR)... 3. BHRF staff will document each medication pass with time and initials. Individuals will initial the MAR after medication administration is completed. 4. ... will document any variance on the MAR and note any changes in medication administration: R-refused, P-pass, H-Hold, A-AWOL, NA-Not Available." 5. In an interview, O2, O3, and O reported medication services were provided as ordered by the medication prescriber, however, O1, O2, and O3 reported not knowing the policy and procedure of documenting any variance on the MAR and noting any changes in medication administration provided to a resident. 6. In an exit interview, O1, O2, O3, and O4 reviewed the findings and no additional statements were made.


summary: Complaint - 9/19/2024

raw_content: An on-site investigation of complaint AZ00209532, AZ00209814, AZ00210137, AZ00212504, AZ00212619, AZ00213774, AZ00214685, AZ00215885 was conducted on September 19, 2024, and the following deficiencies were cited :

rule: C. An administrator shall ensure that: 2. Policies and procedures for behavioral health services and physical health services are established, documented, and implemented to protect the health and safety of a resident that: f. Cover dispensing medication, administering medication, assistance in the self-administration of medication, and disposing of medication, including provisions for inventory control and preventing diversion of controlled substances;

evidence: Based on documentation review and interview, the administrator failed to ensure policies and procedures for behavioral health services were implemented to cover assistance in the self-administration of medication. The deficient practice posed a risk to the health and safety of residents if residents did not receive their required medication and a medication error occurred.

findings: 1. A review of facility documentation revealed a policy titled, "Medication Procedure for BHRF Programs." The policy stated, "... ; IV. Procedures:... E. Administration of Medication: 1. Administration of Medication includes: a. The BHRF Individual reports to the trained BHRF staff for medication administration b. BHRF staff verifies the Individual ' s identity by checking at least two identifiers prior to administering medication c. BHRF staff open the medication container and provides the prescribed dosage to the BHRF Individual d. BHRF staff verify that the BHRF Individual takes the medication in accordance with the 5 Rights of Medication Administration. ; G. Medication Administration Record (MAR): 1. Trained BHRF staff verify the MAR is current and accurate 2. The MAR contains the Individual ' s name, the name of the medication, the dosage and directions for taking the medication and the name of the provider or treating physician 3. BHRF staff will document each medication pass with time and initials. Individuals will initial the MAR after medication administration is completed 4. BHRF staff document any variance on the MAR and note any changes in medication administration: R-refused, P-pass, H- Hold, A- AWOL, NA-Not Available..." 2. A review of facility documentation revealed an event report dated in July 2024 at 2:08 PM. The report stated, "... Medication Event... Incorrect Medication, Dose Omitted... Incident Description: RN was notified that during medication count on 7/.../24 [R8] received an additional dose of Aripiprazole 10 mg at 4:00 PM. [R8] was prescribed Guanfacine 2 mg at 4:00 PM, [R8] did not receive this medication due to staff giving [R8] the Aripiprazole 10 mg; Medication Event: Started Date: 7/.../24; End Date: 7/.../24; Total Number of Medication Events: 2; Additional Medication Event Details: RN was notified that during medication count on 7/.../24 [R8] received an additional dose of Aripiprazole 10 mg at 4:00 PM. [R8] was prescribed Guanfacine 2 mg at 4:00 PM, [R8] did not receive this medication due to staff giving [R8] the Aripiprazole 10 mg; Follow Up: Describe Expected to Follow-Up for any Medical Event: Continue to monitor for side effects, RN has not received any reports of side effects at this time. [R8] has been participating in all activities today and was able to go on the outing yesterday 7/.../24..." 3. A review of facility documentation revealed an incident report dated in March 2024 at 8:10 AM. The report stated, "... Description; Before the Incident: Staff [E8], DCP, BHT set up for medication administration in the medication room; During the Incident: [E8] administered medications to individual [R3] at approximately 7:58 AM. Staff [E8] misread the label on a medication and the medication belonged to another individual. The medication that was wrongfully administered to [R3] was Vyvanse 30mg capsules. Individual [R3] should have received [R3's] prescription Vyvanse 20mg every morning; After the Incident: Staff... was counting medication at approximately 11:00 AM, when staff discovered that the wrong medication was administered to [R3]. Proper notifications were made and reported. Vitals were taken, staff continued to observe for any side effects. Vitals reported to [O1], no further instructions given by doctor. No side effect monitored or reported by staff or [R3]. [R3's] health condition before the medication error was normal. No evidence of illness, or impairment in physical or mental condition. [R3's] health condition after the medication error was normal. No evidence of illness, or impairment in physical or mental condition. The medication error ultimately caused no harm to the individual. Actions taken or recommended include a review of the five rights of medication administration process with the direct care staff. The programs targeted goal will always be to maintain a zero medication rate in all programs but ensure that a medication error rate never exceeds 2% in any reporting period as calculated by # of doses dispensed/med errors." 4. A review of R3's medical record revealed a medication administration record (MAR) dated March 2024. The MAR stated, "... Date: 3/.../24; Hour: 8:00 AM; Reason: Refused didn't want it; Result: Refused, count is off, individual was given the medication from another individual by mistake; Initials: [E8]; Signature: [E8]..." 5. A review of R3's medical record revealed an over the counter/medication standing orders document dated March 7, 2024. The document stated, "... Admit Medications... Vyvanse 20mg morning... Provider Signature: [O1]... Intake Staff: [E3]..." 6. In an exit interview, E2, E5, and E6 stated "medication errors occurred and were identified, addressed, and self-reported."

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure assistance in the self-administration of medication administered to a resident was in compliance with an order and documented in the resident's medical record, for seven out of eights residents sampled. The deficient practice posed a risk to the health and safety of residents if residents did not receive their required medication and a medication error occurred.

findings: 1. A review of facility documentation revealed a policy titled, "Medication Procedure for BHRF Programs." The policy stated, "... E. Administration of Medication: 1. Administration of Medication Includes: a. The BHRF individual reports to the trained BHRF staff for medication administration. b. BHRF staff verifies the individual's identity by checking at least two identifiers prior to administering medication. c. BHRF staff open the medication container and provides the prescribed dosage to the BHRF individual. d. BHRF staff verify that the BHRF individual takes the medication in accordance with the 5 rights of medication administration. e. Staff will encourage individuals to take their medication as ordered and provide medication education as needed. Individual's will not be restrained or forced to take regularly scheduled medications and are to be permitted to refuse medication. Staff will document the refusal in the medication administration record as noted above and notify the nurse on call, who will notify the BHMP provider of any medication refusals to allow for evaluation of potential medication discontinuation or adjustments as needed. Notifications will be made to guardian... G. Medication Administration Record (MAR): 1. Trained BHRF staff verify the MAR is current and accurate. 2. The MAR contains the individual's name, the name of the medication, the dosage and directions for taking the medication and the name of the provider or treating physician. 3. BHRF staff will document each medication pass with time and initials. Individual's will initial the MAR after medication administration is completed. 4. BHRF staff document any variance on the MAR and note any changes in medication administration: R- refused, P-pass, H-hold, A-AWOL, NA- Not Available..." 2. A review of facility documentation revealed an incident report dated in March 2024 at 7:45 AM. The report stated, "... Description; Before the Incident: At approximately 7:44 AM, staff [E7]... was administering medication; During the Incident: Individual [R1] was given Propranolol HCL 10mg one tablet versus the prescribed Propranolol HCL 10mg half a tablet (.5mg); After the Incident: Proper notifications were made and reported. Vitals were taken by staff nurse [E3]... staff continued to observe for any side effects. [O1] notified, instructions were to take vitals now and at 2:00 PM prior to next dose. Vitals wnl. [O1] instructed to continue with the afternoon 2:00 PM dose. No side effects reported or monitored by staff or individual [R1]. Vitals were taken at 10:00 AM BP 113/75, P79, O296 R16, T97.9, vitals at 1:55 PM, BP 117/74, P76, O298, R16, T98.0. [R1's] health condition before the medication error was normal. No evidence of illness, or impairment in physical or mental condition. [R1's] health condition after the medication error was normal, no evidence of illness, or impairment in physical or mental condition. This medication error ultimately caused no harm to the individual. Actions taken or recommended include a review of the five rights of medication administration process with direct care staff. The programs targeted goal will always be to maintain a zero-medication rate in all programs but ensure that a medication error rate never exceeds 2% in any reporting period as calculated by # of doses dispensed/med errors; Individual: [R1]... Event Class: Event, Intervention, Intervention; Event Category: Medical, Medical Interventions, Medical Interventions; Event Type: Medication Error, Nursing Consultation, Physician Consultation; Event Role: Victim/Subject, Victim/Subject, Victim/Subject." 3. A review of R1's medical record revealed a medication administration record (MAR) dated March 2024. The MAR stated, "... Date: 3/19/24; Hour: 7:44 AM; Medication: Propranolol; Reason: Wrong dosage; Result: Med error - one med given instead of .5 (1/2); Initials: [E7]; Staff Signature: [E7]..." 4. A review of R1's medical record revealed an over the counter/admit medication order intake document dated in March 2024. The document stated, "... Admit Medication: Fluoxetine 10mg daily, Propranolol 10mg 1/2 tab PO TID... Admitted from: Hospital/Inpatient; Medications: Delivering from pharmacy, medications match current medication list, medication administration record's made and secured in medication cart... Designated staff member: [E3]..." 5. A review of facility documentation revealed an incident report dated in March 2024 at 8:10 AM. The report stated, "...Description; Before the Incident: Staff [E8]... set up for medication administration in the medication room; During the Incident: [E8] administered medications to individual [R3] at approximately 7:58 AM. Staff [E8] misread the label on a medication and the medication belonged to another individual. The medication that was wrongfully administered to [R3] was Vyvanse 30mg capsules. Individual [R3] should have received [R3's] prescription Vyvanse 20mg every morning; After the Incident: Staff... was counting medication at approximately 11:00 AM, when staff discovered that the wrong medication was administered to [R3]. Proper notifications were made and reported. Vitals were taken, staff continued to observe for any side effects. Vitals reported to [O1], no further instructions given by doctor. No side effect monitored or reported by staff or [R3]. [R3's] health condition before the medication error was normal. No evidence of illness, or impairment in physical or mental condition. [R3's] health condition after the medication error was normal. No evidence of illness, or impairment in physical or mental condition. The medication error ultimately caused no harm to the individual. Actions taken or recommended include a review of the five rights of medication administration process with the direct care staff. The programs targeted goal will always be to maintain a zero medication rate in all programs but ensure that a medication error rate never exceeds 2% in any reporting period as calculated by # of doses dispensed/med errors. Vitals: 12:49 PM - BP 103/68, HR 85, O2 99, Temp 98.2... Individual: [R3]... Event Class: Event, Intervention; Event Category: Medical, Medical Intervention; Event Type: Medication Error, Physician Consultation; Event Role: Victim/Subject, Victim/Subject." 6. A review of R3's medical record revealed a MAR in March 2024. The MAR stated, "... Date: 3/8/24; Hour: 8:00 AM; Reason: Refused didn't want it; Result: Refused, count is off, individual was given the medication from another individual by mistake; Initials: [E8]; Signature: [E8]..." 7. A review of R3's medical record revealed an over the counter/medication standing orders document dated in March 2024. The document stated, "... Admit Medications...Vyvanse 20mg morning... Provider Signature: [O1]... Intake Staff: [E3]..." 8. A review of facility documentation revealed an event report dated in June 2024 at 7:15 PM. The report stated, "... Incident Type: Medication Event... Incident Description: [R4] is scheduled to take 1 mg tablet by mouth at 2:00 PM of Guanfacine. Staff never administered the med to [R4] at the scheduled time frame. Causing this to be a missed medication... Total Number of Medication Events: 1; Additional Medication Event Details: [R4] is scheduled to take 1 tablet by mouth at 2:00 PM of Guanfacine 1 mg. Staff never administered the med to [R4] at the schedul