summary: Complaint - 9/26/2024

raw_content: An on-site investigation of complaint AZ00216493 was conducted on September 26, 2024 and the following deficiencies were cited :

evidence: Based on documentation review, record review, and interview, the administrator failed to implement policies and procedures to protect the health and safety of a resident to cover cardiopulmonary resuscitation (CPR) training to include a demonstration of the individual's ability to perform cardiopulmonary resuscitation. The deficient practice posed a risk if E5 was unable to meet a resident's needs during an accident or emergency, and the facility's standards were not followed.

findings: 1. A review of the facility's policies and procedures revealed a policy titled "Staffing of Residential Facilities- Employees " (dated August 1, 2022). The policy stated "... J. The agency shall provide staff members who have current documentation of successful completion of First Aid and CPR training for adolescents that includes demonstration of the staff member's ability to perform CPR at the facility or on outings." 2. A review of the facility's policies and procedures revealed a policy titled "Cardiopulmonary Resuscitation CPR" (dated August 1, 2022). The policy stated "... b. No online training will be acceptable. All CPR training must be completed in person." 3. A review of facility documentation revealed a daily staffing schedule for September 2024. The schedule revealed E5 was scheduled to work alone on the following dates and the following times: -September 16, 2024: 2:00PM to 11:00PM; -September 20, 2024: 2:00PM to 11:00PM; -September 21, 2024: 9:00AM to 9:00PM; -September 27, 2024: 2:00PM to 10:00PM; and -September 28, 2024: 9:00AM to 9:00PM. 4. A review of E5's (hired in 2024) personnel record revealed E5 was hired as a BHT. E5's personnel record revealed documentation of CPR training from "NationalCPRFoundation" issued January 12, 2024. The document stated "Valid for 2 years." 5. A review of the "NationalCPRFoundation" website revealed courses were conducted online. The "NationalCPRFoundation" website stated the following: -"Help Save Lives Today with Your Online CPR Certification Training!" -"All courses can be completed online in just a few hours or less. Once you have completed an examination via our quick and easy online system, you will receive a PDF copy of your certificate immediately via email as well as your card within 2-5 business days;" and -"Online training is a legal and acceptable form of training, however, NCPRF\'ae does not offer in-person training. Your employer or licensing board may require in-person training for "special industries". You should consult with your employer if you have questions about whether our certification will be accepted. Therefore, we cannot guarantee that our certification will be accepted in every situation." 6. In an interview, E1 reported E1 did not observe E5's demonstration of hands-on [CPR] training. 7. In an interview, the findings were reviewed with E1 and no additional comments or statements were provided regarding the findings.

evidence: Based on record review and interview, the administrator failed to ensure documentation required by Article 7 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 compliance.

findings: 1. The Compliance Officer requested, at 9:18AM and at 11:07AM, E4's documentation of baseline screening consisting of the individual's freedom from infectious TB, per R9-10-113(A)(2)(a)(iii) of two-step testing. However, documentation of E4's two-step testing was not provided for review within two hours after a Department request. 2. The Compliance Officer requested, at 9:18AM and at 11:10AM, E5's documentation of baseline screening consisting of the individual's freedom from infectious TB, per R9-10-113(A)(2)(a)(iii) of two-step testing. However, documentation of E5's two-step testing was not provided for review within two hours after a Department request. 3. In an interview, E1 reported E4 and E5 had documentation of baseline screening consisting of the individual's freedom from infectious TB, per R9-10-113(A)(2)(a)(iii) of two-step testing; however, this documentation was on E1's desk at E1's personal residence. 4. In an interview, the findings were reviewed with E1 and no additional comments or statements were provided regarding the findings. This Rule was cited during the compliance inspection conducted on June 5, 2024. A letter, dated June 12, 2024, stated "Enclosed is a copy of the Statement of Deficiencies (SOD), which describes the violations the Department found at the facility. Because the case has been referred to the Enforcement Team, the Department is not requesting a WRITTEN Plan of Correction (POC) at this time. However, the Department requires that you make immediate corrections of violations that present a threat to the health or safety of a client, resident, patient or agency personnel and still requires that you make corrections to all violations noted in the SOD."

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel member, employee, volunteer, or student to include documentation of cardiopulmonary resuscitation (CPR) training, if required for the individual according to R9-10-703(C)(1)(e); and first aid training, if required for the individual according to this Article or policies and procedures. The deficient practice posed a risk if E2 and E5 were unable to ensure the health and safety of a resident.

findings: 1. A review of the facility's policies and procedures revealed a policy titled "Staffing of Residential Facilities- Employees " (dated August 1, 2022). The policy stated "... J. The agency shall provide staff members who have current documentation of successful completion of First Aid and CPR training for adolescents that includes demonstration of the staff member's ability to perform CPR at the facility or on outings." 2. A review of the facility's policies and procedures revealed a policy titled "Cardiopulmonary Resuscitation CPR" (dated August 1, 2022). The policy stated "... b. No online training will be acceptable. All CPR training must be completed in person." 3. A review of facility documentation revealed a daily staffing schedule for September 2024. The schedule revealed E2 was scheduled to work alone on the following dates and the following times: -September 2, 2024: 6:00PM to 11:00PM; -September 3, 2024: 8:00AM to 2:00PM; -September 4, 2024: 12:00PM to 8:00PM; -September 5, 2024: 6:00PM to 8:00AM; -September 8, 2024: 5:00PM to 8:00AM; -September 9-10, 2024: :700PM to 11:00PM; -September 11, 2024: 8:00AM to 11:00PM; -September 14-15, 2024: 9:00AM to 9:00PM; -September 22, 2024: 9:00AM to 9:00AM; -September 23, 2024: 7:00PM to 11:00PM; -September 25-26, 2024: 7:00PM to 11:00PM; and -September 29, 2024: 9:00AM to 11:00PM. 4. A review of facility documentation revealed a daily staffing schedule for September 2024. The schedule revealed E5 was scheduled to work alone on the following dates and the following times: -September 16, 2024: 2:00PM to 11:00PM; -September 20, 2024: 2:00PM to 11:00PM; -September 21, 2024: 9:00AM to 9:00PM; -September 27, 2024: 2:00PM to 10:00PM; and -September 28, 2024: 9:00AM to 9:00PM. 5. A review of E2's (hired in 2018) personnel record revealed E2 was hired as a behavioral health technician (BHT). The personnel record revealed documentation of CPR training (issued November 8, 2022, expires November 8, 2024). However, documentation of first aid training was not available for review. 6. In an interview, E1 reported E2 completed first aid training, however, this documentation was not available for review. 7. A review of E5's (hired in 2024) personnel record revealed E5 was hired as a BHT. E5's personnel record revealed documentation of CPR training from "NationalCPRFoundation" issued January 12, 2024. The document stated "Valid for 2 years." 8. A review of the "NationalCPRFoundation" website revealed courses were conducted online. The "NationalCPRFoundation" website stated the following: -"Help Save Lives Today with Your Online CPR Certification Training!" -"All courses can be completed online in just a few hours or less. Once you have completed an examination via our quick and easy online system, you will receive a PDF copy of your certificate immediately via email as well as your card within 2-5 business days;" and -"Online training is a legal and acceptable form of training, however, NCPRF\'ae does not offer in-person training. Your employer or licensing board may require in-person training for "special industries". You should consult with your employer if you have questions about whether our certification will be accepted. Therefore, we cannot guarantee that our certification will be accepted in every situation." 9. In an interview, E1 reported E1 did not observe E5's demonstration of hands-on [CPR] training. 10. In an interview, the findings were reviewed with E1 and no additional comments or statements were provided regarding the findings. This Rule was cited during the compliance inspection conducted on June 5, 2024. A letter, dated June 12, 2024, stated "Enclosed is a copy of the Statement of Deficiencies (SOD), which describes the violations the Department found at the facility. Because the case has been referred to the Enforcement Team, the Department is not requesting a WRITTEN Plan of Correction (POC) at this time. However, the Department requires that you make immediate corrections of violations that present a threat to the health or safety of a client, resident, patient or agency personnel and still requires that you make corrections to all violations noted in the SOD."

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\'a7 36-425.03(E)(G), for one of five personnel records sampled. The deficient practice posed a risk if E5 was a danger to a vulnerable population.

findings: A.R.S. \'a7\'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\'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 E5's (hired in 2024) personnel record revealed E5 was hired as a behavioral health technician. E5's personnel record revealed a valid fingerprint clearance card. The personnel record revealed documentation of A.R.S. \'a7\'a7 36-425.03(E) (dated September 12, 2024). However, the document stated " ... True False 1. I am not awaiting trial on or have never been convicted of or admitted in open court or pursuant to a plea agreement committing any of the offenses listed in A.R.S. \'a7\'a7 41-1758.03(B), in this state or similar offenses in another state of jurisdiction" with the "False" checked. 2. In an interview, E1 reported E5's form may have been filled out incorrectly. E1 reported E5 was not awaiting trial and has never been convicted of or admitted in open court or pursuant to a plea agreement committing any of the offenses listed in A.R.S. \'a7\'a7 41-1758.03(B), in this state or similar offenses in another state of jurisdiction. 3. A review of E5's personnel record revealed documentation of compliance with the requirements in A.R.S. \'a7\'a7 36-425.03(G) was not available for review. 4. In an interview, E1 reported E1 contacted E5's previous employers, however, this information was not documented. 5. In an interview, E1 acknowledged E5's personnel record was not maintained to include documentation of compliance with the requirements in A.R.S. \'a7 36-425.03(E)(G). This Rule was cited during the compliance inspection conducted on June 5, 2024. A letter, dated June 12, 2024, stated "Enclosed is a copy of the Statement of Deficiencies (SOD), which describes the violations the Department found at the facility. Because the case has been referred to the Enforcement Team, the Department is not requesting a WRITTEN Plan of Correction (POC) at this time. However, the Department requires that you make immediate corrections of violations that present a threat to the health or safety of a client, resident, patient or agency personnel and still requires that you make corrections to all violations noted in the SOD."

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, employee, volunteer, or student to include documentation of cardiopulmonary resuscitation (CPR) training, if required for the individual according to R9-10-703(C)(1)(e); and first aid training, if required for the individual according to this Article or policies and procedures. The deficient practice posed a risk if E2 and E5 were unable to meet a resident's needs during an accident or emergency.

findings: 1. A review of the facility's policies and procedures revealed a policy titled "Staffing of Residential Facilities- Employees " (dated August 1, 2022). The policy stated "... J. The agency shall provide staff members who have current documentation of successful completion of First Aid and CPR training for adolescents that includes demonstration of the staff member's ability to perform CPR at the facility or on outings. ... M. The agency shall provide one (1) staff member who has current documentation of successful completion of First Aid and CPR training for adolescents ..." 2. A review of the facility's policies and procedures revealed a policy titled "Cardiopulmonary Resuscitation CPR" (dated August 1, 2022). The policy stated "... b. No online training will be acceptable. All CPR training must be completed in person." 3. A review of facility documentation revealed a daily staffing schedule for September 2024. The schedule revealed E2 was scheduled to work alone on the following dates and the following times: -September 2, 2024: 6:00PM to 11:00PM; -September 3, 2024: 8:00AM to 2:00PM; -September 4, 2024: 12:00PM to 8:00PM; -September 5, 2024: 6:00PM to 8:00AM; -September 8, 2024: 5:00PM to 8:00AM; -September 9-10, 2024: :700PM to 11:00PM; -September 11, 2024: 8:00AM to 11:00PM; -September 14-15, 2024: 9:00AM to 9:00PM; -September 22, 2024: 9:00AM to 9:00AM; -September 23, 2024: 7:00PM to 11:00PM; -September 25-26, 2024: 7:00PM to 11:00PM; and -September 29, 2024: 9:00AM to 11:00PM. 4. A review of facility documentation revealed a daily staffing schedule for September 2024. The schedule revealed E5 was scheduled to work alone on the following dates and the following times: -September 16, 2024: 2:00PM to 11:00PM; -September 20, 2024: 2:00PM to 11:00PM; -September 21, 2024: 9:00AM to 9:00PM; -September 27, 2024: 2:00PM to 10:00PM; and -September 28, 2024: 9:00AM to 9:00PM. 5. A review of E2's (hired in 2018) personnel record revealed E2 was hired as a behavioral health technician (BHT). The personnel record revealed documentation of CPR training (issued November 8, 2022, expires November 8, 2024). However, documentation of first aid training was not available for review. 6. In an interview, E1 reported E2 completed first aid training. E1 reported E2's aforementioned documentation of CPR training was the only documentation provided by the training agency. 7. A review of E5's (hired in 2024) personnel record revealed E5 was hired as a BHT. E5's personnel record revealed documentation of CPR training from "NationalCPRFoundation" issued January 12, 2024. The document stated "Valid for 2 years." 8. A review of the "NationalCPRFoundation" website revealed courses were conducted online. The "NationalCPRFoundation" website stated the following: -"Help Save Lives Today with Your Online CPR Certification Training!" -"All courses can be completed online in just a few hours or less. Once you have completed an examination via our quick and easy online system, you will receive a PDF copy of your certificate immediately via email as well as your card within 2-5 business days;" and -"Online training is a legal and acceptable form of training, however, NCPRF\'ae does not offer in-person training. Your employer or licensing board may require in-person training for "special industries". You should consult with your employer if you have questions about whether our certification will be accepted. Therefore, we cannot guarantee that our certification will be accepted in every situation." 9. In an interview, E1 reported E1 did not observe E5's demonstration of hands-on [CPR] training. 10. In an interview, E1 acknowledged a personnel record was not maintained to include documentation of CPR training according to R9-10-703(C)(1)(e) for E5; and and first aid training for E2. This Rule was cited during the compliance inspection conducted on June 5, 2024. A letter, dated June 12, 2024, stated "Enclosed is a copy of the Statement of Deficiencies (SOD), which describes the violations the Department found at the facility. Because the case has been referred to the Enforcement Team, the Department is not requesting a WRITTEN Plan of Correction (POC) at this time. However, the Department requires that you make immediate corrections of violations that present a threat to the health or safety of a client, resident, patient or agency personnel and still requires that you make corrections to all violations noted in the SOD."

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 evidence of freedom from infectious tuberculosis (TB), if required for the individual according to subsection (F); for two of five personnel members sampled. The deficient practice posed a potential TB exposure risk to residents.

findings: R9-10-706(F) An administrator shall ensure that a personnel member, or an employee, a volunteer, or a student who has or is expected to have more than eight hours of direct interaction per week with residents, provides evidence of freedom from infectious tuberculosis: 1. On or before the date the individual begins providing services at or on behalf of the behavioral health residential facility, and 2. As specified in R9-10-113. R9-10-113(A)(2) If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that: 2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, baseline screening, on or before the date specified in the applicable Article of this Chapter, that consists of: iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1). R9-10-113(B)(1)(a)(i) A health care institution's chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specific in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: a. Documentation of a negative Mantoux skin test or other tuberculosis screening test that: i. Is recommended by the U.S. Centers for Disease Control and Prevention (CDC). 1. A review of the CDC website revealed a web page titled " Baseline Tuberculosis Screening and Testing for Health Care Personnel " stated " If the Mantoux tuberculin skin test (TST) is used for baseline testing of health care personnel, use two-step testing." 2. A review of E4's (hired in 2024) personnel record revealed E4 was hired as a behavioral health technician (BHT). E4's personnel record revealed documentation of the individual's freedom from infectious TB (dated September 11, 2024). However, documentation of baseline screening consisting of the individual's freedom from infectious TB, per R9-10-113(A)(2)(a)(iii) of two-step testing, was not available for review. 3. A review of E5's (hired in 2024) personnel record revealed E4 was hired as a behavioral health technician (BHT). E4's personnel record revealed documentation of the individual's freedom from infectious TB (dated September 11, 2024). However, documentation of baseline screening consisting of the individual's freedom from infectious TB, per R9-10-113(A)(2)(a)(iii) of two-step testing, was not available for review. 4. In an interview, E1 reported E4 and E5 had documentation of baseline screening consisting of the individual's freedom from infectious TB, per R9-10-113(A)(2)(a)(iii) of two-step testing; however, this documentation was on E1's desk at E1's personal residence. 5. In an interview, E1 acknowledged E4's and E5's documentation of freedom from infectious TB as specified in R9-10-113 was not available for review.

evidence: Based on record review, observation, and interview, the administrator failed to ensure a resident's medical record contained orders, for one of three current residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper assistance in the self-administration of medication.

findings: 1. A review of R1's (admitted in 2024) medical record revealed a treatment plan (dated in 2024). The treatment plan revealed R1 received assistance in the self-administration of medication. 2. A review of R1's medical record revealed a medication administration record (MAR) for September 2024. The MAR documented R1 received assistance in the self-administration of medication of "Hydroxyzine 25mg" on September 1-25, 2024. However, a signed medication order for the aforementioned medication was not available for review. 3. A review of R1's medical record revealed a document titled "Current Medication List" (date unavailable). The document stated " ... Hydroxyzine TABLET - hydrochloride 25mg Take 1 tablet by mouth at bedtime ..." and "Printed 08/13/2024 ... Page 1 of 1." However, the document was not signed by a medical practitioner. 4. The Compliance Officer observed medication bottle labeled for R1. The label stated "Hydroxyzine HCl 25 mg tablet ... Take 1 tablet by mouth at bedtime for insomnia." However, a signed medication order for Hydroxyzine HCl 25 mg tablet at bedtime was not available for review. 5. In an interview, E1 reported a signed medication order for R1's Hydroxyzine was not available for review. 6. In an interview, E1 acknowledged R1's medical record did not contain a signed medication order for Hydroxyzine. This Rule was cited during the compliance inspection conducted on June 5, 2024. A letter, dated June 12, 2024, stated "Enclosed is a copy of the Statement of Deficiencies (SOD), which describes the violations the Department found at the facility. Because the case has been referred to the Enforcement Team, the Department is not requesting a WRITTEN Plan of Correction (POC) at this time. However, the Department requires that you make immediate corrections of violations that present a threat to the health or safety of a client, resident, patient or agency personnel and still requires that you make corrections to all violations noted in the SOD."

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a resident did not have access to any materials to present a threat to the resident's health or safety based on the resident's documented personal history. The deficient practice posed a risk as a resident had access to marijuana while admitted into a behavioral health residential facility in contradiction with their behavioral health issues.

findings: 1. A review of Department documentation revealed BH6115 was licensed as a behavioral health residential facility for individuals under 18 years of age (children). 2. A review of facility documentation revealed an incident report (dated September 16, 2024). The incident report stated "... While ... @ park member used a friends vape pen to smoke marijuana. Member was on the basketball court playing with school mates who offered [R3] & another client the vape pen- ... member was tested the next day which indicated positive for THC." 3. A review of facility documentation revealed an incident report (dated September 22, 2024). The incident report stated "... Resident #1 came and advised me that [R3] was smoking a vape pen in the room they share. Resident #1 advised me that [R3] still had it and it was hidden in the room. Upon room search I located a weed vape ... When confronted [R3] claimed I planted it there or Resident #1 did. Vape is the same brand of previous on confiscated from [R3] 2 weeks ago." 4. A review of R3's medical record revealed a behavioral health assessment (dated in 2024). The assessment stated " ... Started smoking weed at an early age instead of wanting to take medication. Drug of choice: weed." 5. In an interview, E1 reported R3 must have accessed the marijuana from school. E1 reported searches are conducted using a metal wand, however, residents become creative to avoid detection. 6. In an interview, E1 acknowledged R3 had access to materials to present a threat to the resident's health or safety based on the resident's documented personal history.

evidence: Based on record review, observation, 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 current residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper assistance in the self-administration of medication.

findings: 1. A review of R1's (admitted in 2024) medical record revealed a treatment plan (dated in 2024). The treatment plan revealed R1 received assistance in the self-administration of medication. 2. A review of R1's medical record revealed a medication administration record (MAR) for September 2024. The MAR documented R1 received assistance in the self-administration of medication of "Hydroxyzine 25mg" on September 1-25, 2024. However, a signed medication order for the aforementioned medication was not available for review. 3. A review of R1's medical record revealed a document titled "Current Medication List" (date unavailable). The document stated " ... Hydroxyzine TABLET - hydrochloride 25mg Take 1 tablet by mouth at bedtime ..." and "Printed 08/13/2024 ... Page 1 of 1." However, the document was not signed by a medical practitioner. 4. The Compliance Officer observed medication bottle labeled for R1. The label stated "Hydroxyzine HCl 25 mg tablet ... Take 1 tablet by mouth at bedtime for insomnia." However, a signed medication order for Hydroxyzine HCl 25 mg tablet at bedtime was not available for review. 5. In an interview, E1 reported R1's medication orders were sent straight to the pharmacy. E1 reported a signed medication order for R1's Hydroxyzine was not available for review. 6. In an interview, E1 acknowledged assistance in the self-administration of medication provided to R1 was not in compliance with an order. This Rule was cited during the compliance inspection conducted on June 5, 2024. A letter, dated June 12, 2024, stated "Enclosed is a copy of the Statement of Deficiencies (SOD), which describes the violations the Department found at the facility. Because the case has been referred to the Enforcement Team, the Department is not requesting a WRITTEN Plan of Correction (POC) at this time. However, the Department requires that you make immediate corrections of violations that present a threat to the health or safety of a client, resident, patient or agency personnel and still requires that you make corrections to all violations noted in the SOD."

evidence: Based on observation, record review, and interview, the administrator failed to ensure the premises was maintained in a condition that allowed the premises to be used for the original purpose and free from a condition or situation that may cause a resident or other individual to suffer physical injury.

findings: 1. The Compliance Officer observed the doorknob for R1's bedroom door was missing. 2. The Compliance Officer observed a closet in R1's bedroom. The Compliance Officer observed a metal support bracket in the middle of the closet. However, the support bracket did not give way when the Compliance Officer applied downward pressure. 3. In an interview, E1 reported the doorknob was removed because R1 will lock the door and try to cause self-harm. 4. The Compliance Officer observed a closet in R2's bedroom. The Compliance Officer observed a metal support bracket in the middle of the closet. However, the support bracket did not give way when the Compliance Officer applied downward pressure. 5. A review of R1's (admitted in 2024) medical record revealed a document titled "Client Intake Assessment Packet" (date unavailable). The document stated " ... Current Behavior Concerns: (circle all that apply) Self-Harm" with "Self-Harm" circled. 6. A review of R1's medical record revealed a nursing assessment titled "Initial Health Screen" (dated in 2024). The document stated " ... Tiny scars from self hurt." 7. A review of R2's (admitted in 2024) medical record revealed an untitled document (dated in 2024). The document stated " ... [R2] was referred to ... for suicidal ideation, self-harm, and aggression. ... [Parent] shared that information on referral stating that member was hospitalized for suicidal ideation and self-harming behaviors ..." 8. In an interview, the findings were reviewed with E1 and no additional comments or statements were provided regarding the findings.


state: AZ

facility_name: ANGEL SAFE HAVEN LLC

summary: Complaint - 8/27/2024

raw_content: An on-site investigation of complaint AZ00215076 was conducted on August 27, 2024, and the following deficiencies were cited :

inspection_type: Complaint

rule: I. If an administrator has a reasonable basis, according to A.R.S. § 13-3620 or 46-454, to believe abuse, neglect, or exploitation has occurred on the premises or while a resident is receiving services from a behavioral health residential facility's employee or personnel member, the administrator shall: 1. If applicable, take immediate action to stop the suspected abuse, neglect, or exploitation; 2. Report the suspected abuse, neglect, or exploitation of the resident: a. For a resident 18 years of age or older, according to A.R.S. § 46-454; or b. For a resident under 18 years of age, according to A.R.S. § 13-3620; 3. Document: a. The suspected abuse, neglect, or exploitation; b. Any action taken according to subsection (I)(1); and c. The report in subsection (I)(2); 4. Maintain the documentation in subsection (I)(3) for at least 12 months after the date of the report in subsection (I)(2); 5. Initiate an investigation of the suspected abuse, neglect, or exploitation and document the following information within five working days after the report required in (I)(2): a. The dates, times, and description of the suspected abuse, neglect, or exploitation; b. A description of any injury to the resident related to the suspected abuse or neglect and any change to the resident ' s physical, cognitive, functional, or emotional condition; c. The names of witnesses to the suspected abuse, neglect, or exploitation; and d. The actions taken by the administrator to prevent the suspected abuse, neglect, or exploitation from occurring in the future; and 6. Maintain a copy of the documented information required in subsection (I)(5) and any other information obtained during the investigation for at least 12 months after the date the investigation was initiated.

evidence: Based on documentation review and interview, the administrator failed to ensure if an administrator had a reasonable basis, according to A.R.S. \'a7 46-454, to believe abuse occurred on the premises or while a resident was receiving services from a behavioral health residential facility's employee or personnel member, the administrator took immediate action to stop the suspected abuse; reported the suspected abuse of the resident according to A.R.S. \'a7 46-454; documented the suspected abuse, any action taken according to subsection (I)(1), and the report in subsection (I)(2); maintained the documentation in subsection (I)(3) for at least 12 months after the date of the report in subsection (I)(2); initiated an investigation of the suspected abuse, neglect, or exploitation and documented the following information within five working days after the report required in (I)(2): a. The dates, times, and description of the suspected abuse; b. A description of any injury to the resident related to the suspected abuse and any change to the resident's physical, cognitive, functional, or emotional condition; c. The names of witnesses to the suspected abuse; and, d. The actions taken by the administrator to prevent the suspected abuse from occurring in the future; and maintain a copy of the documented information required in subsection (I)(5) and any other information obtained during the investigation for at least 12 months after the date the investigation was initiated. The deficient practice posed a risk as the facility had a reasonable basis to believe allegations of abuse were reported to the administrator.

findings: 1. A review of facility documentation revealed an email received by E1 dated in August 2024. The email was sent by R2's probation officer reflecting the following information "Hello [E1], I met with [R2]. [R2] seemed happy to see me. Sounds like two kids in the house when they are together bully [R2], are you aware of this? I am concerned for it because [R2] is respectful to most people and [R2] seemed upset about getting bullied when these two youths are together. When they are separated they are nice to [R2]." One day after, E1 responded to the email stating "Good afternoon I am glad your visit went well. I tried to call you at the number listed below to discuss the matter of bullying. Please call me at your convenience." 2. A review of facility documentation revealed documentation of suspected abuse of R2 per R9-10-703(I) or any additional documentation regarding the identified concern or action taken was not available for review. 3. In an interview, E1 reported E1 met with R2 to discuss the reported issue of bullying. E1 reported E1 was notified that two peers were "picking on" R2's cooking and no bullying concerns were reported. E1 reported E1 did not document the contact or actions taken to address the concern with R2. E1 acknowleded E1 did not report the suspected abuse as E1 reported E1 did not have any additional information from the probation officer and the contact with R2 did not lead E1 to believe it met the standards to make a report.

rule: K. An administrator shall ensure that: 3. There is a daily staffing schedule that: a. Indicates the date, scheduled work hours, and name of each employee assigned to work, including on-call personnel members;

evidence: Based on observation, documentation review, and interview, the administrator failed to ensure there was a daily staffing schedule to indicate the name of each employee assigned to work, including on-call personnel members. The deficient practice posed a risk as there was no record to ensure a current behavioral health professional was on-call.

findings: 1. The Compliance Officer observed E1 working at the facility at the time of the inspection. 2. A review of facility documentation revealed daily staffing schedules for August 2024. The facilities schedule provided by E1 revealed on Monday, August 19, 2024, and Monday August 26, 2024, no staff were documented as working 8:00 AM to 2:00 PM. The schedule reflected August 27, 2024, E1 was working as "PRN" with no hours identified. 3. In an interview, E1 reported there were no children at the home during the hours identified. E1 reported E1 was on call and available to come to the facility if needed. E1 acknowledged the staffing schedule did not reflect coverage on the date and hours identified.

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.

findings: 1. A review of R1's and R2's medical records revealed behavioral health assessments completed within the last twelve months from a behavioral health provider other than BH6115. However, documentation of a review and update of R1's and R2's assessment information was not available for review. 2. In an interview, E1 reported R1 and R2's behavioral health assessments were reviewed by the facility BHP. E1 reported E1 was unaware the review was required to be documented after the review was completed. E1 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: 4. Includes: c. The signature of the resident or the resident's representative, and date signed, or documentation of the refusal to sign;

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

findings: 1. A review of R1's medical record revealed a treatment plan dated in August 2024. The treatment plan included the minor residents name and signature. The treatment plan did not include the signature of the resident's representative, and the date signed, or documentation of the refusal to sign. 2. A review of R2's medical record revealed two treatment plans dated in July 2024. The treatment plans included the minor residents name and signature. The treatment plans did not include the signature of the resident's representative, and the date signed, or documentation of the refusal to sign. 3. A review of R3's medical record revealed a treatment plan dated in August 2024. The treatment plan did not include the signature of the resident's representative, and the date signed, or documentation of the refusal to sign. 4. A review of R4's medical record revealed a treatment plan dated in April 2024. The treatment plan included the minor residents name and signature. The treatment plans did not include the signature of the resident's representative, and the date signed, or documentation of the refusal to sign. 5. In an interview, E1 reported E1 emails the treatment plans to the minor residents representative for review and signatures. E1 acknowleged R1's, R2's, R3's, and R4's identified treatment plans did not include the signature of resident's representative, and date signed, or documentation of the refusal to sign.

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

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

findings: 1. A review of R1's medical record revealed a treatment plan dated August 2, 2024. The treatment plan reflected "Treatment Plan Facilitation by: [E5] with no signature and a typed date of "5/22/24."The treatment plan was signed by E1 and E6 however there was no date signed. 2. A review of R3's medical record revealed a treatment plan dated August 2, 2024. The treatment plan reflected "Treatment Plan Facilitation by: [E5] with no signature and a typed date of "5/22/24."The treatment plan was signed by E1 however there was no date signed. The treatment plan included a signature of E6 with a typed date of August 13, 2024. 3. In an interview, E1 reported E1 created R1 and R3's treatment plans and the reflection of E5 creating the treatment plans was a documentation error. E1 reported the treatment plan creation date's reflected on the treatment plans may also be a documentation error as E1 emailed the treatment plans to the BHP after their completion for a signature and review. E1 acknowleged the administrator failed to ensure a treatment plan was fully developed and implemented for each resident to include the signature of the personnel member who developed the treatment plan and the date signed.

rule: A. An administrator shall ensure that 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 was developed and implemented for each resident that, if completed by a behavioral health technician (BHT), was reviewed and signed by a behavioral health professional (BHP) within 24 hours after the completion of the treatment plan to ensure the treatment plan was complete and accurate and met the resident's treatment needs. The deficient practice posed a risk as a description of the resident's behavioral health services to be provided was not reviewed within 24 hours to ensure the treatment plan was complete and accurate.

findings: 1. A review of R1's medical record revealed a treatment plan dated August 2, 2024. The treatment plan included a signature of E1 and E6 however there was no date attached to the signatures. 2. A review of R2's medical record revealed a treatment plan dated July 23, 2024 signed as created by a BHT, E2 on July 23, 2024. However, the treatment plan revealed the BHP reviewed the treatment plan on July 29, 2024. The treatment plan did not include a documented review by the BHP within 24 hours. 3. A review of R3's medical record revealed a treatment plan dated August 2, 2024. The treatment plan was signed by E1 however there was no date signed. The treatment plan included a signature of E6 with a typed date of August 13, 2024. The treatment plan did not include a documented review by the BHP within 24 hours. 4. A review of R4's medical record revealed a treatment plan dated April 24, 2024 signed as created by a BHT, E5 on April 24, 2024. The treatment plan did not include a documented review by a the BHP. 5. In an interview, E1 reported E1 created R1 and R3's treatment plans and the reflection of E5 creating the treatment plans was a documentation error. E1 reported the treatment plan creation date's reflected on the treatment plans may also be a documentation error as E1 emailed the treatment plans to the BHP after their completion for a signature and review. E1 acknowleged the administrator failed to ensure a treatment plan was developed and implemented for each resident that, if 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. This is an uncorrected deficiency from the compliance inspection conducted on June 5, 2024.

rule: A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that: 6. Is reviewed and updated on an on-going basis: a. According to the review date specified in the treatment plan,

evidence: Based on record review and interview, the administrator failed to ensure a treatment plan was developed and implemented for each resident and was reviewed and updated on an on-going basis according to the review date specified in the treatment plan, for one of four residents sampled. The deficient practice posed a risk as an analysis of the resident's needs for behavioral health services was not reviewed and updated.

findings: 1. A review of R2's medical record revealed a treatment plan dated July 23, 2024. The treatment plan identified a review date of "August 19, 2024." No updated treatment plans for R2 were available for review. 2. A review of R4's medical record revealed a treatment plan dated April 24, 2024 . The treatment plan identified a review date of "May 22, 2024." No updated treatment plans for R4 were available for review. 3. In an interview, E1 acknowledged the treatment plans identified were the most current treatment plans for R2 and R4. E1 acknowledged R2's and R4's treatment plans were not reviewed and updated according to the review date specified in the treatment plan.


summary: Complaint;Compliance (Annual) - 6/5/2024

raw_content: The following deficiencies were found during the on-site compliance inspection and investigation of complaint AZ00211204 conducted June 5, 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 to include continued competency training. 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 policy and procedure titled "Fall Prevention and Fall Recovery" (dated May 25, 2023). However, the training program did not include initial training and continued competency training in fall prevention and fall recovery. 2. A review of E2's, E3's, E6's, and E7's personnel records revealed initial training in fall prevention and fall recovery was not available for review. 3. A review of E1's and E5's personnel records revealed continued competency training in fall prevention and fall recovery was not available for review. 4. In an interview, E5 acknowledged a training program for all staff regarding fall prevention and fall recovery to include continued competency training was not developed and administered. This is a repeat deficiency from the on-site compliance inspection conducted on June 19, 2023.

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

findings: 1. A review of R3's (admitted in 2024) medical record revealed a treatment plan (dated in 2024). The treatment plan stated "1 hr wkly group." 2. A review of R3's (admitted in 2024) medical record revealed treatment plan (dated in 2024). The treatment plan revealed R3 received assistance in the self-administration of medication. 3. A review of R4's (admitted in 2023) medical record revealed a treatment plan (dated in 2024). The treatment plan stated "1 hr wkly group." 4. The Compliance Officer requested, on June 5, 2024 at 8:37AM and at 11:35AM, R3's documentation of group counseling sessions for May 2024. However, documentation of R3's group counseling sessions for May 2024 was not provided for review within two hours after a Department request. 5. The Compliance Officer requested, on June 5, 2024 at 8:37AM, R3's documentation of medication orders. However, documentation of R3's medication orders was not provided for review within two hours after a Department request. 6. The Compliance Officer requested, on June 5, 2024 at 8:37AM and at 11:35AM, R4's documentation of group counseling sessions for May 2024. However, documentation of R4's group counseling sessions for May 2024 was not provided for review within two hours after a Department request. 7. In an interview, E5 acknowledged documentation required by Article 7 was not provided to the Department within two hours after a Department request.

rule: K. An administrator shall: 7. If a resident's absence is unauthorized as determined according to the criteria in subsection (K)(6), within an hour after determining that the resident's absence is unauthorized, notify: a. For a resident who is under 18 years of age, the resident's parent or legal guardian; and

evidence: Based on record review and interview, the administrator failed to ensure if a resident's absence was unauthorized, the resident's parent or legal guardian was notified within an hour after determining the resident's absence was unauthorized. The deficient practice posed a risk as the resident was a minor.

findings: 1. A review of R1's medical record revealed a document titled "Angel's Safe Haven Incident Report" (dated May 31, 2024 at 12:45AM). The report stated "Staff was making rounds for the nightly 15min bed checks upon checking staff saw beds empty. After noticing [R1] was gone was able to see bedroom window was left open & appeared client had snuck out the window." The report revealed the Department of Child Safety was notified on May 31, 2024 at 1:00PM; and R1's parent or legal guardian was notified. However, the time R1's parent or legal guardian was notified was not available for review. 2. In an interview, E5 reported R1's parent or legal guardian was notified immediately after R1's unauthorized absence, however, E5 did not know if this information was documented.

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

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

findings: 1. A review of E2's (hired in 2024) personnel record revealed E2 was hired as the BHP. However, E2's personnel record revealed current documentation of contracted services was not available for review. 2. In an interview, E5 was unable to locate documentation of current contracted services for E2, and acknowledged documentation of current contracted services was not maintained for E2.

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

evidence: Based on 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, for two of eight personnel members sampled. The deficient practice posed a risk to the health and safety of residents if a personnel member was not qualified to provide behavioral health services.

findings: 1. A review of E7's personnel record revealed documentation to demonstrate skills and knowledge were verified before E7 provided behavioral health services was not available for review. 2. A review of R3's medical record revealed a medication administration record (MAR) for May 2024. The MAR revealed E7 provided assistance in the self-administration of medication to R3. 3. A review of E8's personnel record revealed documentation to demonstrate skills and knowledge were verified before E8 provided behavioral health services was not available for review. 4. A review of R3's medical record revealed a MAR for May 2024. The MAR revealed E8 provided assistance in the self-administration of medication to R3. 5. In an interview, E5 reported E5 did not know if E7's and E8's skills and knowledge were verified and documented. E5 acknowledged the documentation was not available for review.

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

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure sufficient personnel members were present on 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 if personnel members were unable to meet a resident's needs, or were a danger to a vulnerable population.

findings: 1. A review of facility documentation revealed a policy and procedure titled "Staffing of Residential Facilities - Employees" (dated May 25, 2023). The policy and procedure stated " ... The agency shall provide staff members who have current documentation of successful completion of First Aid and CPR training for adolescents that includes demonstration of the staff member's ability to perform CPR at the facility or on outings." 2. A review of facility documentation revealed a daily staffing schedule for June 2024. The schedule revealed E6 was scheduled to work alone on the following dates and the following times: -June 6, 2024 from 11:00PM to 7:00AM; -June 5-6, 2024 from 11:00PM to 8:00AM; and -June 7-8, 2024 from 11:00PM to 9:00PM. 3. A review of facility documentation revealed daily staffing schedules for May 2024 and June 2024. The schedule revealed E7 was scheduled to work alone on the following dates and the following times: -May 27, 2024 from 3:00PM to 11:00PM; -May 29, 2024 from 3:00PM to 11:00PM; -May 31, 2024 from 3:00PM to 11:00PM; -June 2, 2024 from 9:00AM to 4:00PM; and -June 3, 2024 from 2:00PM to 11:00PM. 4. A review of E6's personnel record revealed documentation of compliance with the requirements in A.R.S. \'a7\'a7 36-425.03(A)(E)(G) was not available for review. 5. A review of E6's (hired in 2024) personnel record revealed E6 was hired as a behavioral health technician (BHT). However, documentation of first-aid and CPR training was not available for review. 6. A review of E7's personnel record revealed documentation to demonstrate skills and knowledge were verified before E7 provided behavioral health services was not available for review. 7. A review of E7's (hired in 2024) personnel record revealed E7 was hired as a BHT. The personnel record revealed E7 had a high school diploma. However, documentation of a bachelor's degree in behavioral health or health related field or a bachelor's degree in any field with two years' work experience in behavioral health service delivery; Job Corp diploma\ certifying completion of academic studies and a combination of behavioral health education and experience working with adolescent youth within a mental health agency totaling a minimum of four years was not available for review. 8. A review of E7's (hired in 2024) personnel record revealed E7 was hired as a BHT. E7's personnel record revealed a valid fingerprint clearance card. However, documentation of compliance with the requirements in A.R.S. \'a7\'a7 36-425.03(E)(G) was not available for review. 9. A review of E7's (hired in 2024) personnel record revealed E7 was hired as a BHT. The personnel record revealed documentation of CPR training (issued May 22, 2024). However, documentation of first-aid training was not available for review. 10. A review of E7's (hired in 2024) personnel record revealed E7 was hired as a BHT. The personnel record revealed documentation of training in assistance in the self-administration of medication. However, the training in assistance in the self-administration of medication was not provided by a medical practitioner or registered nurse or an individual trained by a medical practitioner or registered nurse. 11. A review of E8's (hired in 2024) personnel record revealed E8 was hired as a BHT. E8's personnel record revealed a valid fingerprint clearance card. However, documentation of compliance with the requirements in A.R.S. \'a7\'a7 36-425.03(E) was not available for review. 12. A review of E8's personnel record revealed a criminal history affidavit (date unavailable). The affidavit indicated E8 was not awaiting trial on or had 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. However, the affidavit was not notarized. 13. In an interview, the findings were reviewed with E5 and no additional comments or statements were provided regarding the findings.

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

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

findings: Arizona Administrative Code (A.A.C.) R9-10-113(A)(2) If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that: 2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, baseline screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1). A.A.C. R9-10-113(B)(1)(a)(i) A health care institution's chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specific in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: a. Documentation of a negative Mantoux skin test or other tuberculosis screening test that: i. Is recommended by the U.S. Centers for Disease Control and Prevention (CDC). 1. A review of the CDC website revealed a web page titled " Baseline Tuberculosis Screening and Testing for Health Care Personnel " stated " If the Mantoux tuberculin skin test (TST) is used for baseline testing of health care personnel, use two-step testing." 2. A review of E2's (hired in 2023) personnel record revealed E2 was hired as the behavioral health professional. E2's personnel record revealed documentation of the individual's freedom from infectious TB (dated April 7, 2023). However, documentation of baseline screening consisting of the individual's freedom from infectious TB, per R9-10-113(A)(2)(a)(iii) of two-step testing, was not available for review. 3. A review of E6's (hired in 2024) personnel record revealed E6 was hired as a behavioral health technician (BHT). However, documentation of baseline screening consisting of assessing risks of prior exposure to infectious TB, determining if the individual had signs or symptoms of TB, and E6's freedom from infectious TB, per R9-10-113(A)(2)(a)(iii) of two-step testing, was not available for review. 4. A review of E7's (hired in 2024) personnel record revealed E7 was hired as a BHT. However, documentation of baseline screening consisting of assessing risks of prior exposure to infectious TB, determining if the individual had signs or symptoms of TB, and E7's freedom from infectious TB, per R9-10-113(A)(2)(a)(iii) of two-step testing, was not available for review. 5. A review of E8's (hired in 2024) personnel record revealed E8 was hired as a BHT. E8's personnel record revealed documentation of the individual's freedom from infectious TB (dated April 27, 2023). However, documentation of baseline screening consisting of assessing risks of prior exposure to infectious TB, determining if the individual had signs or symptoms of TB, and E8's freedom from infectious TB, per R9-10-113(A)(2)(a)(iii) of two-step testing, was not available for review. 6. In an interview, E5 acknowledged personnel members did not provide evidence of freedom from infectious TB as specified in R9-10-113. Technical assistance was provided on this Rule during the on-site compliance inspection conducted on June 19, 2023.

rule: G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes: 3. Documentation of: b. The individual's education and experience 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 member to include documentation of the individual's education and experience applicable to the individual's job duties, for one of four behavioral health technicians (BHT) sampled.

findings: 1. A review of facility documentation revealed a policy and procedure titled "Job Descriptions" (dated May 25, 2023). The policy and procedure stated " ... Each staff member will have a written job description listing the duties for that position ... Behavioral Health Technician See attached job description ... Behavioral Health Technician ... Minimal Qualifications: Bachelor's degree in behavioral health or health related field or a bachelor's degree in any field with two years' work experience in behavioral health service delivery; or a high school diploma, or general equivalency diploma (FED) or, Job Corp diploma\ certifying completion of academic studies and a combination of behavioral health education and experience working with adolescent youth within a mental health agency totaling a minimum of four years." 2. A review of facility documentation revealed a policy and procedure titled "Job Descriptions" (dated May 25, 2023). The policy and procedure stated " ... Each staff member will have a written job description listing the duties for that position ... Behavioral Health Technician See attached job description ... Behavioral Health Technician ... Responsibilities and examples of duties Responsible for supportive protective oversight and behavior management; Provide treatment that promotes Consumer dignity, independence, individuality, strengths, privacy, and choice Recognize obvious symptoms of mental disorders, personality disorders or substance abuse. ... Read and implement a Consumer treatment plan." 3. A review of E7's (hired in 2024) personnel record revealed E7 was hired as a BHT. The personnel record revealed E7 had a high school diploma. However, documentation of a bachelor's degree in behavioral health or health related field or a bachelor's degree in any field with two years' work experience in behavioral health service delivery; Job Corp diploma\ certifying completion of academic studies and a combination of behavioral health education and experience working with adolescent youth within a mental health agency totaling a minimum of four years was not available for review. 4. In an interview, E5 reported to not be familiar with E7's education and experience . E5 reported E5 believed E7 went to school for behavioral health. 5. In an interview, E5 acknowledged E7's documentation of education and experience applicable to the individual's job duties 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 compliance with the requirements in Arizona Revised Statutes (A.R.S.) \'a7\'a7 36-425.03(A), for one of eight personnel records sampled, and A.R.S. \'a7\'a7 36-425.03(E)(G), for three of eight personnel records sampled. The deficient practice posed a risk if E6, E7, and E8 were a danger to a vulnerable population.

findings: A.R.S. \'a7\'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\'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\'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 facility documentation revealed a daily staffing schedule for June 2024. The schedule revealed E6 was scheduled to work alone on the following dates and the following times: -June 6, 2024 from 11:00PM to 7:00AM; -June 5-6, 2024 from 11:00PM to 8:00AM; and -June 7-8, 2024 from 11:00PM to 9:00PM. 2. A review of E6's (hired in 2024) personnel record revealed E6 was hired as a behavioral health technician (BHT). E6's personnel record revealed a fingerprint clearance card (issued December 8, 2021). 3. A review of the Arizona Department of Public Safety (AZDPS) Fingerprint Clearance Status website revealed E6's fingerprint clearance card the status was "Not Valid." 4. A review of E6's personnel record revealed documentation of compliance with the requirements in A.R.S. \'a7\'a7 36-425.03(E)(G) was not available for review. 5. In an interview, E5 acknowledged E6's personnel record was not maintained to include documentation of compliance with the requirements in A.R.S. \'a7\'a7 36-425.03(A). 6. A review of E7's (hired in 2024) personnel record revealed E7 was hired as a BHT. E7's personnel record revealed a valid fingerprint clearance card. However, documentation of compliance with the requirements in A.R.S. \'a7\'a7 36-425.03(E)(G) was not available for review. 7. A review of E8's (hired in 2024) personnel record revealed E8 was hired as a BHT. E8's personnel record revealed a valid fingerprint clearance card. However, documentation of compliance with the requirements in A.R.S. \'a7\'a7 36-425.03(E) was not available for review. 8. A review of E8's personnel record revealed a criminal history affidavit (date unavailable). The affidavit indicated E8 was not awaiting trial on or had 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. However, the affidavit was not notarized. 9. In an interview, E5 reported E6's, E7's, and E8's previous employers were contacted; however, this information was not documented. 10. In an interview, E5 acknowledged E6's, E7's, and E8's personnel records were not maintained to include documentation of compliance with the requirements in A.R.S. \'a7 36-425.03(A)(E)(G).

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel record is maintained for each personnel member included documentation of cardiopulmonary resuscitation (CPR) training, if required for the individual according to R9-10-703(C)(1)(e); and first aid training, if required for the individual according to this Article or policies and procedures, for two of eight personnel members sampled. The deficient practice posed a risk if E6 and E7 were unable to meet a resident's needs during an emergency or during an accident.

findings: 1. A review of facility documentation revealed a policy and procedure titled "Staffing of Residential Facilities - Employees" (dated May 25, 2023). The policy and procedure stated " ... The agency shall provide staff members who have current documentation of successful completion of First Aid and CPR training for adolescents that includes demonstration of the staff member's ability to perform CPR at the facility or on outings." 2. A review of facility documentation revealed a daily staffing schedule for June 2024. The schedule revealed E6 was scheduled to work alone on the following dates and the following times: -June 6, 2024 from 11:00PM to 7:00AM; -June 5-6, 2024 from 11:00PM to 8:00AM; and -June 7-8, 2024 from 11:00PM to 9:00PM. 3. A review of facility documentation revealed daily staffing schedules for May 2024 and June 2024. The schedule revealed E7 was scheduled to work alone on the following dates and the following times: -May 27, 2024 from 3:00PM to 11:00PM; -May 29, 2024 from 3:00PM to 11:00PM; -May 31, 2024 from 3:00PM to 11:00PM; -June 2, 2024 from 9:00AM to 4:00PM; and -June 3, 2024 from 2:00PM to 11:00PM. 4. A review of E6's (hired in 2024) personnel record revealed E6 was hired as a behavioral health technician (BHT). However, documentation of CPR training and first aid training was not available for review. 5. A review of E7's (hired in 2024) personnel record revealed E7 was hired as a BHT. The personnel record revealed documentation of CPR training (issued May 22, 2024). However, documentation of first-aid training was not available for review. 6. In an interview, E5 reported E5 believed E6 had documentation of first-aid and CPR training. 7. In an interview, E5 reported E5 was told E7 had first-aid training. 8. In an interview, the findings were reviewed with E5 and no additional comments or statements were provided regarding the findings.

rule: J. An administrator shall ensure that the following personnel members have first-aid and cardiopulmonary resuscitation training specific to the populations served by the behavioral health residential facility: 1. At least one personnel member who is present at the behavioral health residential facility during hours of operation of the behavioral health residential facility, and

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure at least one personnel member was present at the behavioral health residential facility during hours of operation of the behavioral health residential facility who had first-aid and cardiopulmonary resuscitation (CPR) training specific to the populations served by the behavioral health residential facility. The deficient practice posed a risk as E6 and E7 worked alone and did not have first-aid and CPR training.

findings: 1. A review of facility documentation revealed a daily staffing schedule for June 2024. The schedule revealed E6 was scheduled to work alone on the following dates and the following times: -June 6, 2024 from 11:00PM to 7:00AM; -June 5-6, 2024 from 11:00PM to 8:00AM; and -June 7-8, 2024 from 11:00PM to 9:00PM. 2. A review of facility documentation revealed daily staffing schedules for May 2024 and June 2024. The schedule revealed E7 was scheduled to work alone on the following dates and the following times: -May 27, 2024 from 3:00PM to 11:00PM; -May 29, 2024 from 3:00PM to 11:00PM; -May 31, 2024 from 3:00PM to 11:00PM; -June 2, 2024 from 9:00AM to 4:00PM; and -June 3, 2024 from 2:00PM to 11:00PM. 3. A review of E6's (hired in 2024) personnel record revealed E6 was hired as a behavioral health technician (BHT). However, documentation of first-aid and CPR training was not available for review. 4. A review of E7's (hired in 2024) personnel record revealed E7 was hired as a BHT. The personnel record revealed documentation of CPR training (issued May 22, 2024). However, documentation of first-aid training was not available for review. 5. In an interview, E5 reported E5 believed E6 had first-aid and CPR training. 6. In an interview, E5 reported E5 was told E7 had first-aid training. 7. In an interview, the findings were reviewed with E5 and no additional comments or statements were provided regarding the findings. This is a repeat deficiency from the on-site compliance inspection conducted on June 19, 2023.

rule: A. An administrator shall ensure that: 13. Except as provided in subsection (E)(1)(d), a resident provides evidence of freedom from infectious tuberculosis: a. Before or within seven calendar days after the resident's admission, and b. As specified in R9-10-113.

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

findings: Arizona Administrative Code (A.A.C.) R9-10-113(A)(2) 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: Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, baseline screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1). 1. A review of R1's (admitted in 2024) medical record revealed documentation of a Mantoux TB skin test. However, documentation of baseline screening consisting of assessing risks of prior exposure to infectious TB and determining if the individual had signs or symptoms of TB was not available for review. 2. A review of R2's (admitted in 2023) medical record revealed documentation of a Mantoux TB skin test. However, documentation of baseline screening consisting of assessing risks of prior exposure to infectious TB and determining if the individual had signs or symptoms of TB was not available for review. 3. A review of R3's (admitted in 2023) medical record revealed documentation of a Mantoux TB skin test. However, documentation of baseline screening consisting of assessing risks of prior exposure to infectious TB and determining if the individual had signs or symptoms of TB was not available for review. 4. In an interview, the findings were reviewed with E5 and no additional comments or statements were provided regarding the findings. This is a repeat deficiency from the on-site compliance inspection conducted on June 19, 2023.

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 four of four residents sampled. The deficient practice posed a risk as a description of the resident's behavioral health services to be provided was not reviewed within 24 hours to ensure the treatment plan was complete and accurate.

findings: 1. A review of R1's (admitted in 2024) medical record revealed a treatment plan (dated in 2024) completed by a BHT. However, the document was not reviewed and signed by a BHP. 2. A review of R2's (admitted in 2023) medical record revealed a treatment plan (dated in 2024) completed by a BHT. However, the document was not reviewed and signed by a BHP. 3. A review of R3's (admitted in 2024) medical record revealed a treatment plan (dated in 2024) completed by a BHT. However, the document was not reviewed and signed by a BHP. 4. A review of R4's (admitted in 2023) medical record revealed a treatment plan (dated in 2024) completed by a BHT. However, the document was not reviewed and signed by a BHP. 5. In an interview, E5 reported E9 reviewed the treatment plans during staffing meetings. 6. In an interview, E5 acknowledged the BHP did not review and sign R1's, R2's, R3's, and R4's treatment plans within 24 hours after a BHT completed the treatment plan.

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;

evidence: Based on record review and interview, the administrator failed to ensure a discharge summary for a resident, to include the requirements in R9-10-709(G)(2)(a)(i)(ii)(iii), was authenticated by a medical practitioner or behavioral health professional (BHP), for one of two discharged residents sampled. The deficient practice posed a risk as a review of services was not established by the required individual.

findings: R9-10-101.26. "Authenticate" means to establish authorship of a document or an entry in a medical record by: a. A written signature; b. An individual's initials, if the individual's written signature appears on the document or in the medical record; c. A rubber-stamp signature; or d. An electronic signature code. 1. A review of R2's medical record revealed a discharge summary (dated May 2024). The summary stated " ... Completed [R2's] treatment goals at a high 85%." The summary included the requirements in R9-10-709(G)(2)(a)(i)(ii)(iii). However, the summary was not authenticated by a medical practitioner or BHP. 2. In an interview, E5 reported discharge summaries were usually signed by a medical practitioner or BHP. E5 acknowledged R2's discharge summary was not authenticated by a medical practitioner or BHP.

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

evidence: Based on documentation review, record review, observation, and interview, the administrator failed to ensure a resident's medical record contained medication orders, for one of four residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper assistance in the self-administration of medication.

findings: 1. A review of R3's (admitted in 2024) medical record revealed treatment plan (dated in 2024). The treatment plan revealed R3 received assistance in the self-administration of medication. 2. A review of R3's medical record revealed medication orders (dated February 1, 2024) for the following medications: -"Quetiapine 100mg tablet take 1 tablet by oral route 2 times every;" and -"Sertraline 25mg tablet take 1 tablet by oral route every day." 3. A review of R3's medical record revealed a medication administration record (MAR) for May 2024. The MAR documented R3 received assistance in the self-administration of medication on the following dates: -"Quetiapine 25mg 1 tab every evening:" May 1-8, 2024; -"Quetiapine 50mg 1 tab every evening:" May 9-31, 2024; and -"Seroquel 50mg 1 tab every morning:" May 1-31, 2024. However, medication orders for the aforementioned medications were not available for review. 4. The Compliance Officer observed a medication container labeled for R3. The label stated "Quetiapine Fumarate 50mg tab Take 1 tablet by mouth every day at 8 pm." However, a medication order for Quetiapine Fumarate 50mg every day at 8 pm was not available for review. 5. The Compliance Officer observed a medication container labeled for R3. The label stated "Sertraline HCl 50mg tablet Take one tablet by mouth daily at 7:00am." However, a medication order for Sertraline HCl 50mg daily at 7:00pm was not available for review. 6. In an interview, E5 reported E5 was waiting for the current medication orders from R3's medical practitioner. 7. In an interview, E5 acknowledged a resident's medical record did not contain medication orders.

rule: C. An administrator shall ensure that a resident's medical record contains: 15. Documentation of behavioral health services and physical health services provided to the resident;

evidence: Based on record review and interview, the administrator failed to ensure a resident's medical record contained documentation of behavioral health services provided to the resident, for two of two current residents sampled. The deficient practice posed a risk if a resident did not receive treatment to cure, improve, or palliate their behavioral health issue at the health care institution.

findings: 1. A review of R3's (admitted in 2024) medical record revealed a treatment plan (dated in 2024). The treatment plan stated "1 hr wkly group." 2. The Compliance Officer requested, on June 5, 2024 at 8:37AM and at 11:35AM, R3's complete medical record to include documentation of group counseling sessions for May 2024. However, documentation of R3's group counseling sessions for May 2024 was not available for review. 3. A review of R4's (admitted in 2023) medical record revealed a treatment plan (dated in 2024). The treatment plan stated "1 hr wkly group." 4. The Compliance Officer requested, on June 5, 2024 at 8:37AM and at 11:35AM, R4's complete medical record to include documentation of group counseling sessions for May 2024. However, documentation of R4's group counseling sessions for May 2024 was not available for review. 5. In an interview, E5 reported R3 and R4 received group counseling once a week for an hour, however, this documentation was not available. 6. In an interview, E5 acknowledged R3's and R4's medical records were not maintained to contain documentation of behavioral health services provided.

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

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

findings: 1. A review of Department documentation revealed BH6115 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 daily staffing schedule for May 2024. The staffing schedule revealed the facility maintained three shifts with one personnel member generally scheduled per shift. 3. A review of R1's (admitted in 2024) medical record revealed a document titled "Angel's Safe Haven Incident Report" (dated May 28, 2024 at 12:45PM). The report stated " ... Client refused and went to [R1's] room to 'chill out' ... Staff called the house manager ... While on the phone ... staff went outside to check on the other residents who were throwing around a football. When the staff came back inside the front door closed. Another resident stated it was [R1] who walked out the front door. Staff walked out front but did not see [R1] and couldn't tell which direction [R1] went. [Staff] stated to give [R1] 10 minutes to return, then to call emergency services and report [R1's] AWOL. When the client did not return, staff initiated AWOL procedures. ... Client returned to the BHRF at 8pm." 4. In an interview, E5 reported residents are not followed when residents leave the facility and personnel members cannot see where the residents go. E5 reported residents are not followed when residents leave the facility when there is not enough staff to supervise the residents who remained in the facility. 5. In an interview, E5 reported R1's parent convinced R1 to return to BH6115. 6. A review of R1's medical record revealed a document titled "Angel's Safe Haven Incident Report" (dated May 31, 2024 at 12:45AM). The report stated "Staff was making rounds for the nightly 15min bed checks upon checking staff saw beds empty. After noticing [R1] was gone was able to see bedroom window was left open & appeared client had snuck out the window." 7. A review of R3's medical record revealed a document titled "Angel's Safe Haven Incident Report" (dated May 31, 2024 at 12:45AM). The report stated "Upon completing 15min bed checks client was noticed to be missing client had snuck out the game room." 8. The Compliance Officer observed a chair against the concrete fencing in the back yard during a tour of the facility. 9. In an interview, E5 reported the chair was what R1 and R3 used to leave the facility. 10. In an interview, E5 reported the police department found R1. 11. The Compliance Officer observed R3 on the premises during the inspection. 12. In an interview, the findings were reviewed with E5 and no additional comments or statements were provided regarding the findings.

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

evidence: Based on record review and interview, the administrator failed to ensure training for a personnel member, other than a medical practitioner or registered nurse, in assistance in the self-administration of medication was provided by a medical practitioner or registered nurse or an individual trained by a medical practitioner or registered nurse, for one of four behavioral health technicians (BHTs) 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 E7's (hired in 2024) personnel record revealed E7 was hired as a BHT. The personnel record revealed documentation of training in assistance in the self-administration of medication. However, the training in assistance in the self-administration of medication was not provided by a medical practitioner or registered nurse or an individual trained by a medical practitioner or registered nurse. 2. A review of R3's medical record revealed a medication administration record (MAR) for May 2024. The MAR revealed E7 provided assistance in the self-administration of medication to R3. 3. In an interview, E5 reported the registered nurse, E3, has all the documentation of training in assistance in the self-administration of medication. E5 acknowledged training for a personnel member, other than a medical practitioner or registered nurse, in assistance in the self-administration of medication was provided by a medical practitioner or registered nurse or an individual trained by a medical practitioner or registered nurse.

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

findings: 1. A review of R3's (admitted in 2024) medical record revealed treatment plan (dated in 2024). The treatment plan revealed R3 received assistance in the self-administration of medication. 2. A review of R3's medical record revealed medication orders (dated February 1, 2024) for the following medications: -"Quetiapine 100mg tablet take 1 tablet by oral route 2 times every;" and -"Sertraline 25mg tablet take 1 tablet by oral route every day." 3. A review of R3's medical record revealed a medication administration record (MAR) for May 2024. The MAR documented R3 received assistance in the self-administration of medication on the following dates: -"Quetiapine 25mg 1 tab every evening:" May 1-8, 2024; -"Quetiapine 50mg 1 tab every evening:" May 9-31, 2024; and -"Seroquel 50mg 1 tab every morning:" May 1-31, 2024. However, medication orders for the aforementioned medications were not available for review. 4. The Compliance Officer observed medication container labeled for R3. The label stated "Quetiapine Fumarate 50mg tab Take 1 tablet by mouth every day at 8 pm." However, a medication order for Quetiapine Fumarate 50mg every day at 8 pm was not available for review. 5. The Compliance Officer observed medication container labeled for R3. The label stated "Sertraline HCl 50mg tablet Take one tablet by mouth daily at 7:00am." However, a medication order for Sertraline HCl 50mg daily at 7:00pm was not available for review. 6. In an interview, E5 reported E5 was waiting for current medication orders from R3's medical practitioner. 7. In an interview, E5 acknowledged assistance in the self-administration of medication provided to R3 was not in compliance with an order.

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: b. Cleaned and, if applicable, disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection; and

evidence: Based on observation and interview, the administrator failed to ensure the premises was cleaned.

findings: 1. The Compliance Officer observed one bathroom accessible from a common area. 2. The Compliance Officer observed a what appeared to be rust near the shower faucet along the tub. 3. The Compliance Officer observed a discolored shower curtain. 4. In an interview, E5 acknowledged the common bathroom was not cleaned.

rule: B. An administrator shall ensure that: 2. At least one bathroom is accessible from a common area that: c. Contains the following: iii. Toilet tissue for each toilet,

evidence: Based on observation and interview, the administrator failed to ensure at least one bathroom accessible from a common area contained toilet tissue for each toilet. The deficient practice posed an infection control risk.

findings: 1. The Compliance Officer observed one bathroom accessible from a common area. However, the bathroom did not contain toilet tissue for each toilet. 2. In an interview, E5 acknowledged the common bathroom did not contain contain toilet tissue for each toilet.

rule: B. An administrator shall ensure that: 2. At least one bathroom is accessible from a common area that: c. Contains the following: v. Paper towels in a dispenser or a mechanical air hand dryer,

evidence: Based on observation and interview, the administrator failed to ensure at least one bathroom accessible from a common area contained paper towels in a dispenser or a mechanical air hand dryer. The deficient practice posed an infection control risk.

findings: 1. The Compliance Officer observed one bathroom accessible from a common area. However, the bathroom did not contain paper towels in a dispenser or a mechanical air hand dryer. 2. In an interview, E5 acknowledged the common bathroom did not contain paper towels in a dispenser or a mechanical air hand dryer.