summary: Complaint - 3/13/2025

raw_content: An on-site investigation of complaint case 00122096 was conducted on March 13, 2025, and the following deficiency was cited.

rule: R9-10-703.C.1.e.i-iv. Administration C. An administrator shall ensure that: 1. Policies and procedures are established, documented, and implemented to protect the health and safety of a resident that: e. Cover cardiopulmonary resuscitation training including: i. The method and content of cardiopulmonary resuscitation training, which includes a demonstration of the individual's ability to perform cardiopulmonary resuscitation; ii. The qualifications for an individual to provide cardiopulmonary resuscitation training; iii. The time-frame for renewal of cardiopulmonary resuscitation training; and iv. The documentation that verifies that the individual has received cardiopulmonary resuscitation training;

evidence: Based on documentation review, record review, and interview, the administrator failed to administer policies and procedures to ensure the health and safety of a resident, specifically regarding cardiopulmonary resuscitation documentation, which would confirm that the individual had received CPR training. This deficiency posed a health and safety risk to residents.

findings: 1. A review of facility documentation revealed a policy and procedure (reviewed December 2023) titled " Staff Qualifications". The policy stated "13. CPR and First Aid Certification a. Staff providing in-person direct care services are required to show evidence of a valid, in-person CPR and First Aid certification upon hire and are required to continuously maintain certification throughout the term of employment. Proof of skills demonstration is required. CPR/First Aid certified staff are encouraged to render aid as needed, within the scope of their training/certification." 2. A review of facility documentation revealed a staff schedule dated for March 2025. The staff schedule revealed E2 was scheduled to work on March 10, 2025. 3. A review of E2's personnel record revealed evidence of CPR and first aid certification. However, the course was completed online via NationalCPRFoundation. 4. In an interview, O1 reported being unaware whether E2’s training included a demonstration. 5. In an exit interview, the findings were discussed with O1, and no further statements were made. 6. A later review of facility documentation revealed an email verification from NationalCPRFoundation.com. The email stated, “We are online CPR training only. We can verify and confirm [E2] completed an online CPR/AED/First-Aid training course…”

rule: R9-10-706.B.3.a. 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: a. Provide the services in the behavioral health residential facility's scope of services,

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure sufficient personnel members were present on a behavioral health residential facility's premises with the qualifications and experience necessary to meet the needs of a resident and ensure the health and safety of a resident.

findings: 1. A review of facility documentation revealed an incident report dated March 10, 2025. The incident report stated, “On March 10, 2025, at approximately 8:15 PM, [E1] was alerted to a disturbance in the hallway at Desert River. Upon arrival, [E1] observed a member of the facility, [R1], exhibiting erratic behavior, including kicking exit doors, office doors, pulling down ceiling tile, and banging [R1's] head against the wall repeatedly, also punching walls. This action appeared to be deliberate and continuous, causing concern for [R1's] safety and the integrity of the property. Immediately, [E1] called for assistance and attempted to intervene to ensure the member’s safety. [E1] approached them calmly and spoke in a reassuring manner, asking them to stop and to discuss what was troubling them. However, the Member was unresponsive to verbal communication and continued to engage in the destructive behavior. [E1] called for additional staff to the scene to help manage the situation. Meanwhile, [E1] tried to move any nearby objects that could be used to cause further damage or harm. After a few moments, myself and [E2]. Together, we implemented a de-escalation strategy, speaking to members softly and calmly while removing them from the immediate vicinity of the wall. Once the member ceased their actions, we escorted the member to the room, providing [R1] with an ice pack for [R1’s] hand medical evaluation to ensure they had not sustained any injuries. Upon review, we as a team decided [R1] needed further evaluation therefore we transported member.... Patient reported physical pain from the earlier headbanging. On Call Supervisor was contacted at 2022 Patient was transported with staff to [hospital] at 22:22. At 22:46 the medical center, before being medically cleared, member expressed suicidal ideation with a plan to act on it. Residential On-call Supervisor was contacted at 2301. Parents were contacted, initially contacting [O1] at 2300 and then [parent] at 2317. Both phone calls were not answered, and voicemail was left on [parents'] phone. After the triage process, TMC informed staff of torn tissue and ordered X-rays of the body. X-rays were conducted at 2345. TMC staff ordered a consultation with a therapist to assess if member needs to go to a Level 1 Facility (Palo Verde). A scan was completed at 0057 with results pending. The scan was completed at 0056 and the results were returned at 0148. The results showed a boxer fracture on the member's wrist. If the fracture worsens, member would have to see an orthopedic surgeon. The results showed no fracture in the skull, however if the pain persists, member was prescribed Tylenol and ibuprofen. Member was medically cleared, however due to the statements of suicidal ideation that was reported to nursing staff a social worker was recommended to evaluate [R1]. Member was determined to not be a threat or harm to them self or peers by the social worker at 0235. Member and staff returned to desert river at 0325. Member returned to their room after arriving." 2. A review of facility documentation revealed a policy and procedure (reviewed December 2023) titled " Staff Qualifications". The policy stated "13. CPR and First Aid Certification a. Staff providing in-person direct care services are required to show evidence of a valid, in-person CPR and First Aid certification upon hire and are required to continuously maintain certification throughout the term of employment. Proof of skills demonstration is required. CPR/First Aid certified staff are encouraged to render aid as needed, within the scope of their training/certification." 3. A review of facility documentation revealed a staff schedule dated for March 2025. The staff schedule revealed E2 was scheduled to work on March 10, 2025. 4. A review of E2's personnel record revealed evidence of CPR and first aid certification. However, the course was completed online via NationalCPRFoundation. 5. In an interview, O1 reported being unaware whether E2’s training included a demonstration. 6. In an exit interview, the findings were discussed with O1, and no further statements were made. 7. A later review of facility documentation revealed an email verification from NationalCPRFoundation.com. The email stated, “We are online CPR training only. We can verify and confirm [E2] completed an online CPR/AED/First-Aid training course…”


state: AZ

facility_name: INTERMOUNTAIN CENTERS FOR HUMAN DEVELOPMENT, INC

summary: Complaint - 1/27/2025

raw_content: An on-site investigation of complaint AZ00221895 was conducted on January 27, 2025 and no deficiencies were cited.

inspection_type: Complaint


summary: Complaint - 12/18/2024

raw_content: An on-site investigation of complaint AZ00220464 was conducted on December 18, 2024, 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, or had an accident 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 the facility's policies and procedures revealed a policy titled, "Incident Reporting (revised September 14, 2023)," which stated, "For members placed at facilities licensed by the Bureau of Residential Facilities Licensing (BRFL), QI and Compliance must submit written notification of the following within indicated timelines:... 2. Self-injury requiring immediate intervention by an emergency services provider, within two working days of the event." 2. A review of facility documentation revealed a document titled, "Incident, Accident, or Death Report," dated November 30, 2024. The report documented an incident of self-injury inflicted by R2 which required immediate intervention by an emergency medical services provider. The document stated "Member became visibly upset by crying, engaging in loud, inappropriate language. Member self-reported feeling sad due to not being able to reach [their parent] the past few days. Member asked for a 1:1 break in Zen; member punched the wall with [their] right hand and started crying. Staff validated member's feelings and offered member [their] coping skill (drinking water) and a fidget toy. Member was able to deescalate using [their] coping skills. Staff coached member on practicing safe behaviors and encouraged member to continue asking for breaks when [they need] them. Staff gave member ice pack and offered member another fidget toy. On call was notified via phone at 11:19. Staff took member to TMC for x-rays. X-ray showed member having contusion of right hand. ER Doctor wrapped member's hand; practice RICE method and prescribed PRNs Tylenol 650mg and Ibuprofen 600mg. ER Doctor advised member to follow up in a week with Pediatrician. Guardian was notified via phone and left voicemail at 15:27. Staff will continue to monitor member's hand and offer 1:1 breaks and coping tools." 3. A review of facility documentation revealed an incident report dated November 30, 2024 which documented an incident of self-injury inflicted by R4 which required immediate intervention by an emergency medical services provider. The document stated "Member was kicking a soccer ball outside. [Peers were] playing basketball and got in member's way. Peer threw the basketball at member's face, member then charged peer. Member started throwing punches, staff got between member and peer. Member grabbed staff's shirt and held on as they knew if they didn't, they would try and charge peer again. Staff was able to get member inside, member then punched a window and knocked it out. Staff was able to get member to the Zen room where member punched the wall a couple [times] and banged their head. Member was then moved into MPR when they were de-escalated. Member then complained that their hand hurt. Staff observed that it was swollen. Staff call on call at 14:53, on call told staff to take member to TMC urgent care. Member was taken to urgent care where they had an X-ray taken. The X-ray showed that nothing was broken or sprained. Member was prescribed of ibuprofen for the pain. Parent was contacted at 15:27." 4. A review of Department documentation revealed no evidence the Department was notified by the behavioral health residential facility of a resident's self-injury which required immediate intervention by an emergency medical services provider. 5. In an interview, O1 reported the facility began reporting applicable incidents to the Department beginning on December 3, 2024 due to a prior on-site complaint investigation. 6. In an exit interview, E1, O1, and O2 reviewed the findings and no additional statements or documentation was provided. This is a repeated deficiency from the complaint investigation conducted on March 13, 2023, and uncorrected deficiency from November 26, 2024.

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

evidence: Based on observation and interview, the administrator failed to ensure the premises and equipment were maintained in a condition which allowed the premises and equipment to be used for the original purpose of the premises and equipment, cleaned and disinfected, and free from a condition or situation which may have caused a resident or other individual to suffer physical injury. The deficient practice posed a risk to the physical health and safety of a resident.

findings: 1. The Compliance Officer observed two large pools of dried urine, thrown sheets of paper, a used styrofoam drinking cup, torn shreds of cardboard, a belt, and articles of clothing sprawled throughout the floor of R3's bedroom. Additionally, R3's room contained two desktops and a shelf with pink container for storage of R3's personal items. One of the pink containers and a book were placed on the ground surrounded by additional articles of clothing. 2. The Compliance Officer observed two other bedrooms which contained clothing, linens, and other items laid on the floors of the rooms. 3. In an interview, E5 reported room checks were conducted by personnel several times a day for cleanliness and to ensure the physical health and safety of a resident. However, E5 acknowledged not being aware of the messes in R3's and the other resident's rooms due to E5 getting on shift. 4. In an exit interview, E5, O1, and O2 reviewed the findings and no additional statements were made.


summary: Complaint - 11/26/2024

raw_content: An on-site investigation of complaint AZ00219335 was conducted on November 26, 2024, and the following deficiencies were cited :

evidence: Based on documentation review and interview, the administrator failed to ensure written notification to the Department of a residents self-injury within two working days after the resident inflicts a self-injury or has an accident which required immediate intervention by an emergency medical services provider. The deficient practice posed a risk to the health and safety of residents.

findings: 1. A review of facility documentation revealed an incident report dated November 25, 2024. The report stated, " Name: [R1]... Date and Time Tracking: Date of Incident: 11/20/2024; Report Created: 11/25/2024; Submitted T/RHBA: 11/25/2024 4:08:58 PM... Member Diagnoses: F32.3 Major Depressive Disorder, Single Episode, Severe with Psychotic Features; Incident Information: Date of Incident: 11/20/2024; Time of Incident: 10:15 AM... Description of the Incident: At about 10:15 on 11/20/2024, member exhibited DTS behavior by tying a draw string around [R1's] neck and attempting to choke [R1] with it. At the time, staff 1 was with member, and this writer intervened upon observing member starting to tie the draw string around [R1's] neck. Writer utilized a two-finger swoop between members neck and the draw string to prevent member from further tightening the draw string. Writer attempted to utilize verbal de-escalation while maintaining physical intervention, however member was non-verbal to writers attempts. At this point, member had dropped to the floor, and this writer adjusted accordingly to maintain intervention. Writer requested additional assistance from site supervisor and directed... to bring scissors to cut the draw string, as member was declining to respond to verbal prompts. Writer directed staff member to utilize a modified safety hold of members hands from the front of the member as this writer was behind member and a proper safety hold was unable to be completed. This writer assisted site supervisor in cutting the draw string from a safe distance of the members neck, to prevent further injury. Upon draw string being cut, writer instructed staff 1 to release hold. Member was in a modified hold for less than 30 seconds. Member remained on floor, with no visible signs of injury. Writer continued to monitor member and engaged in verbal de-escalation with member. Member provided verbal responses and was engaged with this writer regarding [R1's] thoughts/feelings. Guardian was contacted at 10:40 by site supervisor. It was determined that member required higher level of care, therefore the site supervisor contacted [inpatient facility]. AMR transport was contacted at 13:16. Member was monitored 1:1 from time of incident until AMR transport at 16:15. Guardian was contacted at 16:28 for updates; Incident Type: Safety/Risk Management; Member Condition Before Incident: Member was noncompliant with schedule and staff reported that member may have been in possession of the draw string, however, were unable to verify until time of incident. Member was walking around the DR unit and additionally requesting to speak with this writer; Member Condition After Incident: Member was verbal and engaged following the incident and was able to speak with this writer regarding incident. Member remained in [R1's] room resting/sleeping and was 1:1 with staff; Witnesses: [E10], [E11]; Medical Services Received: Medical services were not provided following incident. Writer conducted check of members neck to ensure no injuries were sustained. Member did not report any pain or discomfort and had no visible signs of injury; Actions Taken and/or Recommended: Staff debriefed with supervisor following the incident. Member was supervised until AMR arrived to transport the member to [inpatient facility]. Member's crisis plan will be updated and reviewed. Staff will follow up with guardian on the member's status; Notifications: Case Management/Assigned CSP/Provider, Parent/Guardian/TSS Case Worker, AMR for transportation; Clinical Director Review: Clinical Director: [E12]; Electronic Signature Date: 11/25/2024; Member has a history of self-harming behaviors in the form of scratching self, biting nails short until they bleed, and cutting. Member has an active crisis plan in [R1's] EHR that was completed on 10/4/2024. Member was assessed for risk on 11/20/2024. Member was transported to [inpatient facility] via AMR on 11/20/2024. The residential RN completed a nurse to nurse with [inpatient facility] prior to member going to [inpatient facility]. Step to prevent further incidents are to have all member remove draw strings from clothing and shoe and will be able to earn the items back once they are on level to engage in community outings (at least 2 weeks). Current member will remove string from clothing and shoes until they are on level to engage in community outings. Guardian was notified and updated throughout crisis..." 2. A review of facility documentation revealed an email submitted by [E12] to the Department of Medical Licensing dated November 25, 2024 at 4:16 PM. 3. In an interview, E1 reported R1 did not suffer any injuries during the incident and did not require emergency medical services. E1 also reported R1 was transported to a facility with higher level of care following the incident.

rule: K. An administrator shall: 5. Establish and document the process for responding to a resident's need for immediate and unscheduled behavioral health services or physical health services;

evidence: Based on documentation review, record review and interview, the administrator failed to establish and document the process for responding to a resident's need for immediate and unscheduled behavioral health services or physical health services. The deficient practice posed a risk to the health and safety of residents.

findings: 1. A review of facility documentation revealed an incident report dated November 25, 2024. The report stated, " Name: [R1]... Date and Time Tracking: Date of Incident: 11/20/2024; Report Created: 11/25/2024; Submitted T/RHBA: 11/25/2024 4:08:58 PM... Member Diagnoses: F32.3 Major Depressive Disorder, Single Episode, Severe with Psychotic Features; Incident Information: Date of Incident: 11/20/2024; Time of Incident: 10:15 AM... Description of the Incident: At about 10:15 on 11/20/2024, member exhibited DTS behavior by tying a draw string around [R1's] neck and attempting to choke [R1] with it. At the time, staff 1 was with member, and this writer intervened upon observing member starting to tie the draw string around [R1's] neck. Writer utilized a two-finger swoop between members neck and the draw string to prevent member from further tightening the draw string. Writer attempted to utilize verbal de-escalation while maintaining physical intervention, however member was non-verbal to writers attempts. At this point, member had dropped to the floor, and this writer adjusted accordingly to maintain intervention. Writer requested additional assistance from site supervisor and directed... to bring scissors to cut the draw string, as member was declining to respond to verbal prompts. Writer directed staff member to utilize a modified safety hold of members hands from the front of the member as this writer was behind member and a proper safety hold was unable to be completed. This writer assisted site supervisor in cutting the draw string from a safe distance of the members neck, to prevent further injury. Upon draw string being cut, writer instructed staff 1 to release hold. Member was in a modified hold for less than 30 seconds. Member remained on floor, with no visible signs of injury. Writer continued to monitor member and engaged in verbal de-escalation with member. Member provided verbal responses and was engaged with this writer regarding [R1's] thoughts/feelings. Guardian was contacted at 10:40 by site supervisor. It was determined that member required higher level of care, therefore the site supervisor contacted [inpatient facility]. AMR transport was contacted at 13:16. Member was monitored 1:1 from time of incident until AMR transport at 16:15. Guardian was contacted at 16:28 for updates; Incident Type: Safety/Risk Management; Member Condition Before Incident: Member was noncompliant with schedule and staff reported that member may have been in possession of the draw string, however, were unable to verify until time of incident. Member was walking around the DR unit and additionally requesting to speak with this writer; Member Condition After Incident: Member was verbal and engaged following the incident and was able to speak with this writer regarding incident. Member remained in [R1's] room resting/sleeping and was 1:1 with staff; Witnesses: [E10], [E11]; Medical Services Received: Medical services were not provided following incident. Writer conducted check of members neck to ensure no injuries were sustained. Member did not report any pain or discomfort and had no visible signs of injury; Actions Taken and/or Recommended: Staff debriefed with supervisor following the incident. Member was supervised until AMR arrived to transport the member to [inpatient facility]. Member's crisis plan will be updated and reviewed. Staff will follow up with guardian on the member's status; Notifications: Case Management/Assigned CSP/Provider, Parent/Guardian/TSS Case Worker, AMR for transportation; Clinical Director Review: Clinical Director: [E12]; Electronic Signature Date: 11/25/2024; Member has a history of self-harming behaviors in the form of scratching self, biting nails short until they bleed, and cutting. Member has an active crisis plan in [R1's] EHR that was completed on 10/4/2024. Member was assessed for risk on 11/20/2024. Member was transported to [inpatient facility] via AMR on 11/20/2024. The residential RN completed a nurse to nurse with [inpatient facility] prior to member going to [inpatient facility]. Step to prevent further incidents are to have all member remove draw strings from clothing and shoe and will be able to earn the items back once they are on level to engage in community outings (at least 2 weeks). Current member will remove string from clothing and shoes until they are on level to engage in community outings. Guardian was notified and updated throughout crisis..." 2. In an interview, E1 reported there was no specific policy and procedure on responding to a resident's need for immediate and unscheduled behavioral health services or physical health services. E1 also reported there was a policy titled, " Emergency and First Aid," that could possibly cover the topic. 3. A review of facility documentation revealed a policy titled, "Emergency and First Aid." The policy stated, " Purpose: To ensure Intermountain Centers for Human Development, Inc. (Intermountain Centers) and its affiliates are equipped with the supplies, medications, and necessary equipment to respond to emergencies and render first aid. Each site maintains staff who are trained to respond to emergencies and render first aid... Policy: Intermountain Centers maintain systems for monitoring the availability of needed emergency response and first aid equipment and supplies so staff can respond appropriately and safely to both emergent and non-emergent incidents; Procedures: A. Any time Intermountain Centers staff encounter an emergency that is an immediate threat to the life or health of a member or other individual while on Intermountain premises or while in the field, Intermountain staff are to call 911 B. Staff who are certified in CPR and First Aid will render emergency care to a member or individual while awaiting the arrival of first responders, and/or per the direction of first responders while they are enroute C. Staff certified in CPR and First Aid may administer first aid or assists in responding to minor or non-life-threatening injuries in which basic First Aid is the appropriate medical intervention D. Staff are oriented to the location of emergency and/or First Aid supplies and equipment and are provided instruction regarding the sight designee responsible for monitoring the inventory and use of the supplies and equipment..." 4. In an interview, E1 acknowledged the policy and procedure titled, " Emergency and First Aid," did not cover responding to a resident's need for immediate and unscheduled behavioral health services or physical health services.

rule: A. An administrator shall ensure that: 7. A resident does not: a. Use or have access to any materials, furnishings, or equipment or participate in any activity or treatment that may present a threat to the resident's health or safety based on the resident's documented diagnosis, treatment needs, developmental levels, social skills, verbal skills, or personal history; or

evidence: Based on documentation review, record review and interview, the administrator failed to ensure a resident does not use or have any access to any materials, furnishings, or equipment or participate in any activity or treatment which may present a threat to the resident or share any space, participate in any activity or treatment, or verbally or physically interact with any other resident that may present a threat to the residents health or safety. The deficient practice posed a risk to the health and safety of R1 as a negative outcome occurred.

findings: 1. A review of facility documentation revealed an incident report dated November 25, 2024. The report stated, " Name: [R1]... Date and Time Tracking: Date of Incident: 11/20/2024; Report Created: 11/25/2024; Submitted T/RHBA: 11/25/2024 4:08:58 PM... Member Diagnoses: F32.3 Major Depressive Disorder, Single Episode, Severe with Psychotic Features; Incident Information: Date of Incident: 11/20/2024; Time of Incident: 10:15 AM... Description of the Incident: At about 10:15 on 11/20/2024, member exhibited DTS behavior by tying a draw string around [R1's] neck and attempting to choke [R1] with it. At the time, staff 1 was with member, and this writer intervened upon observing member starting to tie the draw string around [R1's] neck. Writer utilized a two-finger swoop between members neck and the draw string to prevent member from further tightening the draw string. Writer attempted to utilize verbal de-escalation while maintaining physical intervention, however member was non-verbal to writers attempts. At this point, member had dropped to the floor, and this writer adjusted accordingly to maintain intervention. Writer requested additional assistance from site supervisor and directed... to bring scissors to cut the draw string, as member was declining to respond to verbal prompts. Writer directed staff member to utilize a modified safety hold of members hands from the front of the member as this writer was behind member and a proper safety hold was unable to be completed. This writer assisted site supervisor in cutting the draw string from a safe distance of the members neck, to prevent further injury. Upon draw string being cut, writer instructed staff 1 to release hold. Member was in a modified hold for less than 30 seconds. Member remained on floor, with no visible signs of injury. Writer continued to monitor member and engaged in verbal de-escalation with member. Member provided verbal responses and was engaged with this writer regarding [R1's] thoughts/feelings. Guardian was contacted at 10:40 by site supervisor. It was determined that member required higher level of care, therefore the site supervisor contacted [inpatient facility]. AMR transport was contacted at 13:16. Member was monitored 1:1 from time of incident until AMR transport at 16:15. Guardian was contacted at 16:28 for updates; Incident Type: Safety/Risk Management; Member Condition Before Incident: Member was noncompliant with schedule and staff reported that member may have been in possession of the draw string, however, were unable to verify until time of incident. Member was walking around the DR unit and additionally requesting to speak with this writer; Member Condition After Incident: Member was verbal and engaged following the incident and was able to speak with this writer regarding incident. Member remained in [R1's] room resting/sleeping and was 1:1 with staff; Witnesses: [E10], [E11]; Medical Services Received: Medical services were not provided following incident. Writer conducted check of members neck to ensure no injuries were sustained. Member did not report any pain or discomfort and had no visible signs of injury; Actions Taken and/or Recommended: Staff debriefed with supervisor following the incident. Member was supervised until AMR arrived to transport the member to [inpatient facility]. Member's crisis plan will be updated and reviewed. Staff will follow up with guardian on the member's status; Notifications: Case Management/Assigned CSP/Provider, Parent/Guardian/TSS Case Worker, AMR for transportation; Clinical Director Review: Clinical Director: [E12]; Electronic Signature Date: 11/25/2024; Member has a history of self-harming behaviors in the form of scratching self, biting nails short until they bleed, and cutting. Member has an active crisis plan in [R1's] EHR that was completed on 10/4/2024. Member was assessed for risk on 11/20/2024. Member was transported to [inpatient facility] via AMR on 11/20/2024. The residential RN completed a nurse to nurse with [inpatient facility] prior to member going to [inpatient facility]. Step to prevent further incidents are to have all member remove draw strings from clothing and shoe and will be able to earn the items back once they are on level to engage in community outings (at least 2 weeks). Current member will remove string from clothing and shoes until they are on level to engage in community outings. Guardian was notified and updated throughout crisis..." 2. A review of R1's medical record revealed a comprehensive assessment dated October 4, 2024. The assessment stated, " What Are You Seeking Help for Today?:.. Presenting issues: Member was referred to the AIC for self-injury, suicidal behavior, and reporting hallucinations; Self-injury: Guardian reports that member has a hx of cutting, hitting head on wall, and hitting knuckles on tables and biting [R1's] lip and fingers until they bleed. Member reported that [R1] acts on self-harm when [R1] is feeling depressed. Guardian additionally reported that member has been "purging"; Suicidal behavior: Guardian reported that member has been exhibiting suicidal behaviors since February, stating the member has disclosed SI and plan to school counselor... Guardian states that [R1] has not witnessed suicidal behavior. Member reported that [R1] reports SI to counselor, stating that [R1] informed counselor that [R1] was going to "hang [R1]"; Reporting Hallucinations: Guardian reports that member hears voices "all the time" and that they are "whispers"; Guardian states that member has command AH and they will tell member to harm [R1]. Member reports that AH is in the form of whispering and that they will whisper [R1's] name. Member reports hearing whispers throughout the day, however they only command member when [R1] is triggered. Member states that [R1's] triggers include arguing and banging. Member reported that [R1] currently is not hearing voices upon return from [facility], Member was discharged from the AIC to [facility] on 5/29/23 due to self-harm... Past Risk and Alerts: History of non-suicidal/self-injurious behavior: Yes; Please Elaborate: Member has hx of self-harming behaviors, to include cutting. Member will additionally bite [R1's] nails 'very short' until they bleed and will engage in scratching; Imminent Stressors?: No; Does Individual Have Current of Past Difficulties with Anger Management?: No; Has the Individual Ever Been Destructive to Property?: No; Has Individual Ever Been Violent Towards Persons?: Yes, 05/30/2024, [facility] Staff; Did Violence Result in Injury?: No; Did Violence Ever Involved the Use of a Weapon?: No..." 3. In an interview, E1 reported R1 acquired the draw string from R1's sport shorts. 4. In an interview, E1 reported R1 was discharged to a higher level of care following the incident.


summary: Complaint - 10/31/2024

raw_content: An on-site investigation of complaints AZ00218014, AZ00218033, AZ00218034, AZ00218041, and AZ00218159 was conducted on October 31, 2024 and no deficiencies were cited.


summary: Complaint - 10/23/2024

raw_content: An on-site investigation of complaint AZ00217723 was conducted on October 23, 2024 and no deficiencies were cited.


summary: Complaint - 10/1/2024

raw_content: An on-site investigation of complaint AZ00213440, AZ00215912 and AZ00216145 was conducted on October 1, 2024 and the following deficiencies were cited :

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 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 qualifications, including skills and knowledge applicable to the individual's job duties, for one of seven personnel members sampled. The deficient practice posed a risk if E10 was not qualified to work in a health care institution.

findings: R9-10-706.B.1.a.b. An administrator shall ensure that: The qualifications, skills, and knowledge required for each type of personnel member: a. Are based on: The type of behavioral health services or physical health services expected to be provided by the personnel member according to the established job description, and The acuity of the residents receiving behavioral health services or physical health services from the personnel member according to the established job description; and Include: The specific skills and knowledge necessary for the personnel member to provide the expected behavioral health services or physical health services listed in the established job description, The type and duration of education that may allow the personnel member to have acquired the specific skills and knowledge for the personnel member to provide the expected behavioral health services or physical health services listed in the established job description, and The type and duration of experience that may allow the personnel member to have acquired the specific skills and knowledge for the personnel member to provide the expected behavioral health services or physical health services listed in the established job description; 1. A review of E10's (hired in February 2024, behavioral health technician) personnel record revealed documentation of the verification of qualifications, including skills and knowledge was not available for review. 2. In a joint interview, E1, E2, and E12 acknowledged documentation of the verification of E10's qualifications, including skills and knowledge was not available for review.

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

evidence: Based on documentation review, record review and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of the individual's completed orientation, for one of seven personnel members. The deficient practice posed a risk if a personnel member was not qualified to work in a health care institution.

findings: R9-10-101.155. "Orientation" means the initial instruction and information provided to an individual before the individual starts work or volunteer services in a health care institution. R9-10-706.E.1.2.3.An administrator shall ensure that: A plan to provide orientation specific to the duties of a personnel member, an employee, a volunteer, and a student is developed, documented, and implemented; A personnel member completes orientation before providing behavioral health services or physical health services; An individual's orientation is documented, to include: The individual's name, The date of the orientation, and The subject or topics covered in the orientation; 1. A review of E6's (hired in October 2023, behavioral health technician) personnel record revealed documentation of completed orientation was not available for review. 2. In a joint interview, E1, E2, and E12 acknowledged documentation of E6's completed orientation was not available for review.


summary: Complaint - 8/20/2024

raw_content: An on-site investigation of complaints AZ00214724 and AZ00214715 was conducted on August 20, 2024 and the following deficiency was cited :

evidence: Based on record review, documentation review, observation, and interview, the administrator failed to ensure a resident did not have access to any materials to present a threat to the resident's health or safety based on the resident's documented diagnosis and treatment needs. The deficient practice posed a risk as a resident had access to a broken marker cap, and inflicted a self-injury, while admitted into a behavioral health residential facility in contradiction with their behavioral health issue.

findings: 1. A review of R1's (admitted in 2024) electronic medical record revealed a behavioral health assessment (dated June 2024). The assessment stated " ... Member was reported as having the following behaviors: self-harm, SI, and aggression..." 2. A review of electronic documentation revealed an incident report (dated in August 2024). The incident report stated "...member's roommate alerted staff that peer was self harming. Staff immediately went into room and found member bleeding from [R1's] wrist from 2 cuts. Member was holding something in [R1's] hand and staff asked to have it...it was a broken marker cap..." 3. A review of facility documentation revealed a document titled "Incident Accident Or Death Report" (dated August 9, 2024). The document stated "...Member was transported...due to self-harm..." 4. In an interview, E1 reported R1 self-harmed by a broken marker cap. 5. In a joint interview, E1 and E2 acknowledged a resident had access to materials to present a threat to the resident's health or safety based on the resident's documented diagnosis and treatment needs.


summary: Complaint;Compliance (Annual) - 7/11/2024

raw_content: The following deficiencies were found during the on-site compliance inspection and investigation of complaint AZ00212189 conducted on July 11, 2024:

inspection_type: Complaint;Compliance (Annual)

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

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

findings: 1. A review of facility documentation revealed a training program for fall prevention and fall recovery was not available for review. 2. A review of E8's electronic personnel record revealed initial training dated in 2022. However, continued competency training in fall prevention and fall recovery was not available for review. 3. In an interview, E1 reported all personnel members are required to complete initial and annual fall prevention and recovery training. E1 reported BH7317 did not develop policies and procedures specific to fall prevention and fall recovery training.

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

evidence: Based on documentation review, record review, and interview, the administrator failed to implement policies and procedures to protect the health and safety of a resident to cover cardiopulmonary resuscitation (CPR) training to include a demonstration of the individual's ability to perform CPR. The deficient practice posed a risk if E8 was unable to meet a resident's needs during an emergency, accident, or injury; and the standards expected of employees were not followed.

findings: 1. A review of the facility's policies and procedures revealed a policy titled "Staff Qualifications" (dated in December 2023). The policy stated "...Staff providing in-person direct care services are required to show evidence of a valid, in-person CPR and First Aid certification upon hire and are required to continuously maintain certification throughout term of employment. Proof of skills demonstration is required..." 2. A review of E8's electronic personnel record revealed documentation of CPR training from "NationalCPRFoundation" issued July 11, 2024 and valid until July 11, 2026. 3. A review of the NationalCPRFoundation website revealed courses were conducted online. The NationalCPRFoundation website stated "Help Save Lives Today with Your Online CPR Certification Training!" 4. A review of the facility's daily staffing schedules revealed no evidence E8 worked alone. 5. In an interview, E1 reported E8 had not worked alone. 6. In a joint interview, E1 and E2 acknowledged E8's CPR training did not include a demonstration of the individual's ability to perform CPR and the policy and procedure was not implemented.

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 was developed for each resident to include the behavioral health services to be provided to the resident, for four of four current residents sampled, and for one of one discharged resident sampled. The deficient practice posed a risk if a resident did not receive treatment to cure, improve, or palliate their behavioral health issue at the health care institution.

findings: 1. A review of R1's medical record revealed a treatment plan (dated in June 2024). The treatment plan did include the frequency of counseling to be provided to the resident. However, the treatment plan did not include the number of hours of counseling to be provided to R1. 2. A review of R2's medical record revealed a treatment plan (dated in June 2024). The treatment plan did include the frequency of counseling to be provided to the resident. However, the treatment plan did not include the number of hours of counseling to be provided to R2. 3. A review of R3's medical record revealed a treatment plan (dated in June 2024). The treatment plan did include the frequency of counseling to be provided to the resident. However, the treatment plan did not include the number of hours of counseling to be provided to R3. 4. A review of R4's medical record revealed a treatment plan (dated in April 2024). The treatment plan did include the frequency of counseling to be provided to the resident. However, the treatment plan did not include the number of hours of counseling to be provided to R4. 5. A review of R5's medical record revealed a treatment plan (dated in April 2024). The treatment plan did include the frequency of counseling to be provided to the resident. However, the treatment plan did not include the number of hours of counseling to be provided to R5. 6. In a joint interview, E1 and E2 acknowledged R1's, R2's, R3's, R4's, and R5's treatments plan did not include the number of hours of counseling to be provided to R1, R2, R3, R4, and R5.


summary: Complaint - 6/20/2024

raw_content: An on-site investigation of complaint AZ00211833 was conducted on June 20, 2024 and no deficiencies were cited.


summary: Complaint - 5/3/2024

raw_content: An on-site investigation of complaint AZ00209816 was conducted on May 3, 2024 and the following deficiencies were cited :

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

evidence: Based on record review and interview, the administrator failed to ensure a personnel record included documentation of cardiopulmonary resuscitation (CPR) and first aid training, for two of six personnel members sampled. The deficient practice posed a risk if safety measures were not in place to meet a resident's needs.

findings: 1. A review of E3's personnel record revealed the documentation of CPR and first aid training had an expiration date of January 10, 2024. 2. A review of E3's personnel record revealed the documentation of CPR and first aid training had an expiration date of August 2023. 3. In an interview, E1 acknowledged E3 and E6 did not have current documentation of CPR and first aid training.

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

evidence: Based on documentation review and interview, the administrator failed to ensure a resident was treated with dignity, respect and consideration. The deficient practice posed a risk as residents' rights were violated.

findings: 1. A review of facility documentation revealed an incident report dated April 20, 2024. The report stated "At 16:48, member [R1] was escalated due to another peer. Member was kicking door and head banging ...member then grabbed a piece of ceiling tile and self-harmed with it once again and staff had to physically remove it again." 2. In an interview, R1 stated "I am not treated with respect, I am given attitude by E5". R1 reported E5 pushed R1 a few weeks ago when R1 was "upset" about another resident ' s interaction with personnel members and the police. R1 stated "I wanted to leave the situation, I didn ' t listen to TPD and was pushed by staff." R1 stated "I was triggered by anxiety. I wanted to breathe but they said they didn ' t have enough staff to go on break right away." 3. In an interview, E1 confirmed an incident for R1 that occurred on April 20, 2024. E1 reported R1 had a history of self-harm and aggression.

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

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

findings: 1. The Compliance Officer observed a hallway in the facility that contained all the resident bedrooms. The Compliance Officer observed a camera on the ceiling in the hallway. 2. A review of facility documentation revealed an incident report dated May 1st, 2024. The report stated "a peer [R2] had entered the member's [R3] room on the night of 4/22/24. Footage was reviewed and the peer was in the member's room for 25 mins ...the member stated multiple times that no form of physical activity had occurred, though the peer had since reported to an outside party that they had sexual contact. That outside party informed the site on 5/1/2024 at 10:38am ..." 3. A review of R3's medical record revealed a behavioral health assessment dated in 2023. The assessment indicated R3 had a history of "sexual abuse", "physical abuse", and "emotional abuse." 4. In an interview, E1 reported R2 reported R2 had sexual contact with R3 on April 22, 2023. E1 reported R2 was in R3's bedroom from 9:35 PM to 10 PM. E1 stated R3 reported R2 "came into the room while [R3] was sleeping." E1 reported the bedrooms were checked by staff every 15 minutes. 5. In an interview, E1, E2, O1, O2, and O3, acknowledged the facility did not provide continuous protective oversight over R2 and R3.


summary: Complaint;Compliance (Annual) - 12/12/2023

raw_content: The following deficiencies were found during the on-site compliance inspection and investigation of complaint AZ00203827 conducted on December 12, 2023:

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 one of three personnel sampled. The deficient practice posed a risk if a personnel member was unable to meet a resident's needs.

findings: 1. A review of the facility policies and procedures (revised in 2021) revealed a policy titled, "Orientation and Training." The policy stated, "Initial competency of skills prior to working unsupervised: New staff will participate in training required to meet requirements set forth by the contractual agreements as relevant to each person's job duties and responsibilities. Initial competency will be based on skills acquired during the training period along with prior experience and qualifications; Skills verification will be acquired and initially assessed at the end of the 40-hour orientation period via observation, written testing and/or verbal acquisition; The training period of initial skills acquisition and competency will be provided in multiple training forums to include: New Hire Training, clinical site orientation, classroom training, online training and in-house and/or external training; At the end of the training period an Initial Skills and Knowledge verification Form will be completed on each staff member and verification will be authenticated by the training coordinator or program director." 2. A review of E5's personnel record revealed E5 was hired as a Behavioral Health Professional (BHP) in February 2022. E5's personnel record revealed E5's skills and knowledge were not verified until May 2023, after providing behavioral health services to residents. 3. A review of the facility documentation revealed a staffing schedule. The schedule revealed E5 was scheduled to work Monday-Friday from 9 a.m. to 5 p.m. beginning from E5's hire date until May 2023 when E5's skills and knowledge was verified. 4. In an interview, E1 acknowledged E5's skills and knowledge had not been verified and documented before providing behavioral health services and according to policies and procedures.

rule: G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes: 3. Documentation of: g. If the individual is a behavioral health technician, clinical oversight required in R9-10-115;

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of clinical oversight, for one of two behavioral health technicians (BHT's) who provided counseling services. The deficient practice posed a risk to the health and safety of residents if BHT's provided clinical services they were not licensed to provide without clinical oversight by a licensed behavioral health professional (BHP).

findings: 1. A review of the facility policy and procedure (revised in 2021) revealed a policy titled, "Clinical Oversight" The policy stated, "All Intermountain Centers staff providing behavioral health services receive regular clinical oversight from a qualified Behavioral Health Professional (BHP) in accordance with state laws and regulations... All full-time and part-time BHTs and BHPPs receive clinical oversight at least once during each two week period, if the BHT or BHPP provides services related to client care during the two week period. Clinical oversight is provided by BHPs or LIPs with skills and knowledge in the behavioral health services provided and the populations served by Intermountain Centers." 2. A review of R3's medical record revealed seven counseling notes dated throughout November 2023. The counseling notes were signed by E4. 3. A review of E4's personnel record revealed no documentation of clinical oversight for November 2023. 4. In an interview, E1 acknowledged E4's personnel record did not contain documentation of clinical oversight for the month of November 2023.


facility_name: CAMELBACK KIDS

summary: Complaint - 3/12/2026

raw_content: No deficiencies were found during the on-site investigation of complaint 00157322 conducted on March 12, 2026.


summary: Complaint;Compliance (Annual) - 8/19/2025

raw_content: The following deficiencies were found during the on-site compliance inspection and investigation of complaint 00141348 conducted on August 19, 2025:

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

evidence: Based on record review and interview, the chief administrative officer failed to implement tuberculosis (TB) infection control activities including baseline screening consisting of assessing risks of prior exposure to infectious TB, determining if the individual had signs or symptoms of TB, and the individual's freedom from infectious TB. The deficient practice posed a potential TB exposure risk to residents.

findings: 1. A review of R1's medical record revealed a negative Mantoux skin test. However, documentation assessing risks or prior exposure to infectious TB and determining if R1 had signs or symptoms of TB was not provided for review. 2. A review of R2's medical record revealed a negative Mantoux skin test. However, documentation assessing risks or prior exposure to infectious TB and determining if R2 had signs or symptoms of TB was not provided for review. 3. In an exit interview. E1 reviewed the findings and no additional documentation was provided for review.

rule: R9-10-703.M.1-3. Administration M. An administrator shall ensure that the following information or documents are conspicuously posted on the premises and are available upon request to a personnel member, employee, resident, or a resident's representative: 1. The behavioral health residential facility's current license, 2. The location at which inspection reports required in R9-10-720(C) are available for review or can be made available for review, and 3. The calendar days and times when a resident may accept visitors or make telephone calls.

evidence: Based on observation and interview, the administrator failed to ensure the location at which inspection reports required in R9-10-720(C) are available for review or can be made available for review was conspicuously posted on the premises.

findings: 1. The Compliance Officer observed several facility postings. However, a posting about the inspection reports location was not observed. 2. In an exit interview, E1 reviewed the findings and reported E1 will create a posting for the inspection reports.

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

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel member that included the individual's in-service education as required by policies and procedures. The deficient practice posed a risk to the health and safety of residents if staff were unfit to use the emergency safety response.

findings: 1. A review of facility documentation revealed a policy titled, "Emergency Safety Response." The policy stated, "Camelback Kids utilizes emergency safety responses. All staff members are trained in verbal de-escalation techniques and to initiate a 911 call while maintaining the safety of all other clients." 2. A review of facility documentation revealed a policy titled, "Training Plan Policy and Procedure." The policy stated, "... Documentation requirements... Crisis management (CPI); within first 90 days; annually..." 3. A review of E1's, E2's, E3's, E4's, E5's, E6's, and E7's personnel records revealed no documentation of current CPI training. 4. In an exit interview, E1 reviewed the findings and reported CPI trainings were renewed for all staff, but did not have the documentation available.

rule: R9-10-706.G.3.e. Personnel G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes: 3. Documentation of: 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 that included documentation of the individual's compliance with requirements in A.R.S. §§ 36-411 and 36-425.03. The deficient practice posed a risk to the health and safety of residents as the personnel member had contact with a vulnerable population without a notarized affidavit.

findings: A.R.S. § 36-425.03. "E. Children's behavioral health program personnel shall certify on forms that are provided by the department and notarized that they are not awaiting trial on or have never been convicted of or admitted in open court or pursuant to a plea agreement to committing any of the offenses listed in section 41-1758.03, subsection B or C in this state or similar offenses in another state or jurisdiction." 1. A review of E5's personnel record revealed a criminal history affidavit dated July 8, 2025. However, the criminal history affidavit was not notarized. 2. In an exit interview, E1 reviewed the findings, and no additional documentation was provided for review.

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

evidence: Based on record review and interview, the administrator failed to ensure a personnel record was maintained for each personnel member that included documentation of the individual's compliance with the requirements in A.R.S. § 8-804. The deficient practice posed a risk to the health and safety of residents if staff were unfit to work at a children's behavioral health residential facility.

findings: A.R.S. § 8-804.C "C. Licensees that do not contract with the state and that employ persons who provide direct services to children pursuant to title 36, chapter 7.1 must submit to the department of child safety in a manner prescribed by the department of child safety information necessary to conduct central registry background checks. The department of health services shall verify whether licensees, pursuant to title 36, chapter 7.1, have complied with the requirements of this subsection and any rules adopted by the department of health services to implement this subsection." 1. A review of E1's, E2's, E3's, E4's, E5's, E6's, and E7's personnel records revealed no documentation of verification that personnel were not on the central registry. 2. In an exit interview, E1 reviewed the findings, and no additional documentation was provided for review.

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

evidence: Based on record review and interview, the administrator failed to ensure counseling was provided according to the frequency and number of hours identified in the resident's treatment plan. The deficient practice posed a risk to the health and safety of residents if residents did not receive the required counseling.

findings: 1. A review of R1's medical record revealed a master treatment plan dated July 2025. The plan stated, "... Objective 1; Interventions: Group therapy 2 times per week/ Individual therapy 1 time per week... Objective 2; Interventions: Family therapy (telephonic) 1 time per month/ Group therapy 2 times per week/ Individual therapy 1 time per week... Objective 3; Interventions: Group therapy 2 times per week/ Individual therapy 1 time per week... Objective 4; Interventions: Group therapy 2 times per week/ Individual therapy 1 time per week... Objective 5; Interventions: Family therapy (telephonic) 1 time per month/ Group therapy 2 times per week/ Individual therapy 1 time per week..." However, the number of hours of counseling to be provided was not documented. 2. A review of R2's medical record revealed a master treatment plan dated June 3, 2025. The plan stated, "... Objective 1; Interventions: Group therapy 2 times per week/ Individual therapy 1 time per week... Objective 2; Interventions: Family therapy (telephonic) 1 time per month/ Group therapy 2 times per week/ Individual therapy 1 time per week... Objective 3; Interventions: Group therapy 2 times per week/ Individual therapy 1 time per week... Objective 4; Interventions: Group therapy 2 times per week/ Individual therapy 1 time per week..." However, the number of hours of counseling to be provided was not documented. 3. In an exit interview, E1 reviewed the findings and reported E1 will ensure treatment plans contain the number of hours of counseling to be provided.

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

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

findings: 1. A review of R1's medical record revealed the following medication orders: Aripiprazole 5MG Tab, take 1 tablet by mouth every night at bedtime; and Melatonin 5MG Tab, take 1 tablet by mouth every night at bedtime. 2. A review of R1's medical record revealed a medication administration record (MAR) dated July 2025. The MAR revealed the following medications were not administered at bedtime as ordered: 1. Aripiprazole 5MG tab administered in the morning on July 18, 2025; and 2. Melatonin 5MG tab administered in the morning on July 18, 2025. 3. A review of R1's medical record revealed a MAR dated August 2025. The MAR revealed the following medications were not administered: 1. Aripiprazole 5MG tab from August 11, 2025, to August 16, 2025, and August 18, 2025. 2. Melatonin 5Mg tab on August 18, 2025. 4. In an exit interview, E1 reviewed the findings and reported issues refilling R1's medication. E1 also reported E1 was looking at other pharmacies to fill the prescription.

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

evidence: Based on observation and interview, the administrator failed to ensure poisonous or toxic materials stored by the behavioral health residential facility were maintained in a locked area and inaccessible to residents. The deficient practice posed a risk to the health and safety of residents, as residents had access to poisonous or toxic materials.

findings: 1. The Compliance Officer observed the following items in the master bedroom's bathroom: "Radiance" toilet bowl cleaner and "Windex" window cleaner. 2. In an exit interview, E1 reviewed the findings and no additional statements were made.


summary: Compliance (Annual) - 5/22/2024

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on May 22, 2024:

inspection_type: Compliance (Annual)

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

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

findings: 1. A review of facility documentation revealed a staffing schedule for May 2024. The staffing schedule revealed E3 was the BHP on-call. 2. A review of facility policies and procedures revealed a policy titled "Contracted Services" which stated, "Camelback Kids will have written agreements with the following professionals to provide Services: Behavioral Health Professional: Camelback Kids will have a written agreement with a Behavioral Health Professional to provide clinical oversight, review treatment plans, assessments and counseling and to ensure that treatment is provided according to the goals established in the treatment plan ...The BHP must also be available on-call as needed." 3. A review of E3's personnel record revealed E3 was hired as the facility's licensed BHP. E3's personnel record revealed an offer letter dated November 2, 2022 which stated, "We are pleased to offer you the position of Licensed Professional Counselor at SCL College of Nursing, DBA Camelback Kids ...This position serves as an Independent Contractor providing counseling services to our residents at Camelback Kids." However, no further description of contracted services provided was available in E3's personnel record. 4. In an interview, E1 reported E3 was available on call and completed behavioral health assessments and treatment plans for residents. E1 acknowledged a documentation of these contracted services was not provided for E3.

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 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 skills and knowledge applicable to the individual's job duties, for two of seven personnel members sampled. The deficient practice posed a risk if a personnel member was not qualified to work in a healthcare institution,

findings: 1. A review of facility policies and procedures revealed a policy titled, "REQUIREMENTS FOR ALL PERSONNEL POLICY AND PROCEDURE" which stated, "All licensed and non-licensed staff/behavioral health professionals must have the following skills and knowledge verified by the Clinical Director prior to delivering behavioral health services. A signed skills check-list will be submitted demonstrating proof ..." 2. A review of E4's personnel record revealed E4 was hired as the facility's registered nurse (RN). However, documentation which demonstrated E4's skills and knowledge were verified and documented, was not available for review. 3. A review of E6's personnel record revealed E6 was hired as a behavioral health technician (BHT). E6's personnel record revealed a "Personnel Orientation" and "Verification of Skills and Knowledge" checklist from "Gem House, Ebenezer, Angel Heart LLC." Both checklists were completed before E6 was hired at BH7444. No documentation which demonstrated E6's skills and knowledge were verified and documented at BH7444 was available for review. 4. In an interview, E1 reported E4's and E6's skills and knowledge were verified and documented. However, E1 could not locate the documentation. E1 acknowledged documentation to demonstrate E4's and E6's skills and knowledge were verified and documented was not available for review.

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

evidence: Based on record review and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of compliance with the requirements in Arizona Revised Statutes (A.R.S.) \'a7 36-411(A)(C)(1), for four of seven personnel members sampled. The deficient practice posed a health and safety risk to residents if personnel members were a danger to a vulnerable population.

findings: 1. A.R.S. \'a7 36-411(C)(1) states: "Owners shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency." 2. A review of E1's, E2's, E3's, and E4's personnel records revealed valid fingerprint clearance cards. However, documentation of compliance with A.R.S. \'a7 36-411(C)(1) for E1, E2, E3, and E4 was not available for review. 3. In an interview, E1 reported E1 believed E1's, E2's, E3's, and E4's previous employers were contacted. However, E1 acknowledged documentation of compliance with A.R.S. \'a7 36-411(C)(1) was not available for review in E1's, E2's, E3's, or E4's personnel records.

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

evidence: Based on record review and interview, the administrator failed to ensure if a medical practitioner performed a medical history and physical examination or a nurse performed a nursing assessment on a resident before admission, the medical practitioner entered an interval note or the nurse entered a progress note in the resident's medical record within seven calendar days after admission, for one of two residents sampled. The deficient practice posed a risk as this information was required for the development and implementation of a treatment plan, per R9-10-708.A.1.

findings: 1. A review of R1's medical record revealed a medical history completed 13 days prior to R1 ' s admission to BH7444. However, there was no documentation to indicate a medical practitioner or nurse entered an interval note or progress note on the assessment in R1's medical record within seven calendar days after R1's admission to the facility. 2. In an interview, E1 acknowledged no progress note or interval note was entered in R1's medical record within seven days of R1's admission.

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

evidence: Based on record review and interview, the administrator failed to ensure a behavioral health assessment in compliance with the requirements in this Section, received from a behavioral health provider other than the behavioral health residential facility, was reviewed, updated, and documented in the resident's medical record within 48 hours after the review was completed. The deficient practice posed a risk as the Department was unable to determine compliance as the documentation was not in the medical record during the inspection.

findings: 1. A review of R1's medical record revealed behavioral health assessments completed within the last twelve months from a behavioral health provider other than BH7444. However, documentation of a review and update of R1's assessment information was not available for review. 2. In an interview, E2 reported R1's behavioral health assessment was reviewed by the facility BHP. E2 reported E2 was unaware the review was required to be documented and updated within 48 hours after the review was completed. E2 acknowledged the administrator failed to ensure a behavioral health assessment in compliance with the requirements in this Section, received from a behavioral health provider other than the behavioral health residential facility, was reviewed, updated, and documented in the resident's medical record within 48 hours after the review was completed.

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

evidence: Based on record review and interview, the administrator failed to ensure a treatment plan completed by a behavioral health technician (BHT) was reviewed and signed by a behavioral health professional (BHP) within 24 hours after the completion of the treatment plan, for one of two residents sampled.

findings: 1. A review of R1's medical record revealed a treatment plan dated July 15, 2023. The treatment plan was signed and dated by E2, a BHT. 2. In an interview, E2 reported E2 completed R1's treatment plan. E2 reported E2 believed R1's treatment plan was reviewed by E3, but was unaware the treatment plan had to be reviewed and signed by a BHP within 24 hours of completion. E2 acknowledged R1's treatment plan was not reviewed and signed by a BHP within 24 hours after the completion of the treatment plan.

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

evidence: Based on record review, documentation review, and interview, the administrator failed to ensure assistance in the self-administration of medication provided to a resident was provided in compliance with an order, for one of three residents 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 R2's medical record revealed a medication order, dated March 28, 2024 for "Strattera (capsule), 25mg (1 capsule), every morning, Take after breakfast for ADHD symptoms." 2. Further review of R2's medical record revealed a medication administration record (MAR) for May, 2024. R2's May MAR revealed R1 received assistance in the self administration of "Atomoxetine [Strattera] 40mg, 1 capsule" on May 1-19, 2024. R2's record contained no medication order for the increased dose (40mg) of Strattera. 3. In an interview, E1 reported E4 had ordered an increase in the dosage of R2's Strattera. However, E1 was unable to locate the medication order for this increased dosage. E1 acknowledged assistance in the self-administration of medication was not provided to R2 in compliance with available orders.

rule: B. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 6. Documentation of each evacuation drill is created, is maintained for 12 months after the date of the evacuation drill, and includes: a. The date and time of the evacuation drill; b. The amount of time taken for all employees and residents to evacuate the behavioral health residential facility; c. Names of employees participating in the evacuation drill; d. An identification of residents needing assistance for evacuation; e. Any problems encountered in conducting the evacuation drill; and f. Recommendations for improvement, if applicable;

evidence: Based on documentation review and interview, the administrator failed to ensure documentation of each evacuation drill included names of employees participating in the evacuation drill, an identification of residents needing assistance for evacuation, any problems encountered in conducting the evacuation drill, and recommendations for improvement, if applicable. The deficient practice posed a risk as the Department was unable to ensure the facility was prepared in case of an evacuation.

findings: 1. A review of Department documentation revealed the perpetual license for BH7444 was effective April 26, 2022. 2. A review of facility documentation revealed a facility staffing schedule for May, 2024. The May schedule indicated the facility maintained two shifts: -7:00 AM to 7:00 PM; and -7:00 PM to 7:00 AM. 3. A review of facility documentation revealed "Fire" drills for employees and residents were conducted on the following dates and times: -June 7, 2023 at 10:22 AM; -June 16, 2023 at 6:06 PM; -June 29, 2023 at 6:43 PM; -June 30, 2023 at 11:00 PM; -July 28, 2023 at 2:27 PM; -July 30, 2023 at 7:00 PM; -September 15, 2023 at 6:40 AM; -September 26, 2023 at 7:15 AM; -November 3, 2023 at 7:35 AM; -December 29, 2023 at 8:13 AM; -January 25, 2024 at 5:01 PM; -February 4, 2024 at 1:20 AM; -March 5, 2024 at 12:05 AM; -March 13, 2024 at 8:00 AM; -March 13, 2024 at 7:15 PM; and -April 28, 2024 at 8:30 PM. However, the documentation did not include the names of employees participating in the evacuation drills, an identification of residents needing assistance for evacuation, any problems encountered in conducting the evacuation drills, and recommendations for improvement, if applicable. 4. In an interview, E1 reported the facility's documented "Fire" drills were evacuation drills for employees and staff. E1 acknowledged documentation of each evacuation drill did not include the names of employees participating in the evacuation drills, an identification of residents needing assistance for evacuation, any problems encountered in conducting the evacuation drills, and recommendations for improvement, if applicable. E1 reported E1 was unaware of these requirements.