summary: Compliance (Annual) - 3/18/2025

raw_content:
The following deficiencies were cited during the unannounced, on-site State Compliance survey conducted on March 11, 2025 through March 14, 2025, with Inspection number INSP-0100717, pursuant to the rules found in Arizona Administrative Code (A.A.C.) Title 9, Chapter 10, Article 1- General and Article 13 - Behavioral Health Specialized Transitional Facility.

Healthcare Compliance Officers
March 21, 2025

rule: R9-10-1302.C.1.z. Administration C. An administrator shall: 1. Ensure that policies and procedures are established, documented, and implemented that: z. Include equipment inspection and maintenance;

evidence: Based on observation during facility tour conducted on March 14, 2024, review of facility documents, request for facility policy and procedure, and employee interview during facility tour, the Department determined that the administrator failed to ensure Daily Medical Emergency Cart/AED Inspection Logs for both Acacia and Mesquite units were completed accurately. This deficient practice could result in emergency medical equipment not functioning properly, posing a risk to the health and safety of patients.

findings: Facility documents titled "Daily Emergency Medical Cart/AED Inspection Log" posted within staff offices for both Acacia and Mesquite units, observed during facility tour, presented with entries for the last "cart opened and contents checked" date documented on Day 17 of March 2025. The date of review for the facility documents was March 14, 2025. Facility policy and procedure addressing completion of the "Daily Emergency Medical Cart/AED Inspection Log" was requested. None was provided. Employees #1 and #3 confirmed in joint interview, conducted on March 14, 2025, that the "Daily Emergency Medical Cart/AED Inspection Log" posted within staff offices for both Acacia and Mesquite units presented with entries for the last "cart opened and contents checked" date documented on Day 17 of March 2025.


state: AZ

facility_name: Arizona Community Protection And Treatment Center

summary: Complaint - 3/18/2025

raw_content:
The following deficiency was cited during the unannounced, on-site State Complaint Investigation survey conducted on March 11, 2025, through March 14, 2025, with Inspection number INSP-0097108, pursuant to the rules found in Arizona Administrative Code (A.A.C.) Title 9, Chapter 10, Article 1- General and Article 13 - Behavioral Health Specialized Transitional Facility, for the following case numbers:

Case #00108776
Case #00082426

Healthcare Compliance Officers, March 21, 2025

inspection_type: Complaint

rule: R9-10-1302.C.1.r. Administration C. An administrator shall: 1. Ensure that policies and procedures are established, documented, and implemented that: r. Cover quality management, including incident reports and supporting documentation;

evidence: Based on facility policy and procedure, facility documents, medical records and employee interview, the Department determined the administrator failed to ensure that facility policy was followed covering supporting documentation of incident reports involving allegations of patient to patient sexual contact. This deficient practice poses a risk to patient health and safety when the facility does not fully address issues that impact the quality of patient care.

findings: Policy titled “Sexual Interaction Between Residents,” Approval Effective Date: 07/15/2024, revealed “…A. OBSERVED OR REPORTED SEXUAL ACTIVITY BETWEEN RESIDENTS…The medical provider shall:…b. in the event of other reported sexual contact, the medical provider shall determine the need for a physical exam or laboratory testing for sexually transmitted diseases and document the decision for/against an exam/testing as well as the outcome of the exam/testing if completed….” Facility document titled “50 March 2025 IRs” revealed “…ASH-2025-0403…2/3/25 10:30…ACPTC…Sexual activity between patients…(Patient #4)…(Patient #5)…” Facility document titled “50 January 2025 IRs” revealed “…ASH-2025-0397…1/27/25 9:45…ACPTC…Sexual activity between patients…(Patient #11)…” Medical record for Patient #4 revealed “…Progress Note…Treatment team reviewed a report regarding (Patient #4)…On 2/3/25, during a clinical meeting…(Unidentified Patient) seemed to acknowledge engaging in sexual behavior with (Patient #4)… Electronically signed by: (Employee #11) on 02/06/2025 at 03:27 PM MST…” Request was made for medical provider documentation of determination of need for physical exam or laboratory testing for sexually transmitted diseases. None was provided. Medical record for Patient #5 revealed “…Progress Note…Treatment team reviewed a report from (Patient #5). On 2/3/25, during a clinical meeting…(Patient #5) seemed to indicate (Patient #5) and (Patient #4) engaged in sexual touch and exposing to each other on one occasion in the Rehab bathroom…. Electronically signed by: (Employee #11) on 02/06/2025 at 03:25 PM MST” Request was made for medical provider documentation of determination of need for physical exam or laboratory testing for sexually transmitted diseases. None was provided. Medical record for Patient #11 revealed “…Progress Note…This writer spoke with (Patient #11)…to follow up regarding a report that (Patient #11) had been observed engaging in sexual activity with another resident…Electronically signed by: (Employee #11) on 02/05/2025 at 09:12 AM MST…” Request was made for medical provider documentation of determination of need for physical exam or laboratory testing for sexually transmitted diseases. None was provided. Employee #1 confirmed during interviews conducted between March 12, 2025 to March 14, 2025, that no medical provider documentation of determination of need for physical exam or laboratory testing for sexually transmitted diseases was available for review for Patients #4, #5, and #11 at the time of the survey.


summary: Complaint - 3/26/2024 - 4/4/2024

raw_content: The following deficiency was cited at the time of the unannounced, State Complaint Investigation survey, Event # 62E111, conducted on March 26, 2024 through April 4, 2024 pursuant to the rules found in 9 A.A.C. 10 - Article 13: Behavioral Health Specialized Transitional Facility, for the following intakes: AZ00201408 AZ00200514 AZ00200513 AZ00199621 AZ00196606 AZ00196038 AZ00195374 AZ00195336 AZ00195097 Ted Murphy Norman Sartor, MHI Healthcare Compliance Surveyors April 10, 2024

rule: R9-10-1302. Administration C. An administrator shall: 1. Ensure that policies and procedures are established, documented, and implemented that: t. Cover restraint and seclusion;

evidence: Based on a review of policy and procedures, observation, facility documents, medical records, and staff interview, the Department determined policies and procedures were not correctly implemented in the application of a patient restraint. This deficient practice resulted in a patient falling and needing further evaluation for injuries.

findings: A review of the "Behavioral Emergency - Code Grey Situation" revealed "...Any staff member confronted with or witnessing a combative situation should initiate a Code Grey, and begin de-escalation strategies consistent with NVCI (Non-Violent Crisis Intervention)...The Code Gray Response Team...De-escalate potentially violent behavior...." A review of the "Seclusion or Restraint" policy last reviewed on September 30, 2021 revealed "...Purpose To establish and implement guidelines for the safe utilization of seclusion or restraint....Application of Restraint...The type or technique of restraint used must be the least restrictive intervention effective to protect the resident or others from harm....Releasing a secluded or restrained Resident...A secluded or restrained resident is released as soon as the resident exhibits behaviors as defined by the release criteria...upon termination of the emergency necessitating the seclusion or restraint..." A review of the "Incident Reports" policy last reviewed on July 29, 2020 revealed "...Policy The Arizona Community Protection and Treatment Center requires the electronic submission of an Incident Report for all events which are significant...These events are to be reported fully, accurately...by the person with the greatest knowledge of the event, in order to provide dependable documentation for possible further investigation and action....Incomplete or inaccurate Incident Reports will be sent back to the originator for correction....The Quality Management Team reviews all Incident Reports each business day, dispositions the Incident Reports for additional review...and codes them appropriately for external reporting purposes...." Observation of the video surveillance without sound from the incident on May 26, 2023, revealed Patient # 11 approach a seated Patient # 4 and berate him face to face while standing over him. Employee # 11 walks directly in front of the two patients at this point heading into the dayroom. Employee # 11 then returns the way he came passing in front of the two patients again but still does not intervene or attempt to de-escalate. Employee # 18 is nearby in the nursing bubble watching the event but also does not attempt to de-escalate the potentially violent behavior. Patient # 11 then begins to punch the still seated Patient # 4. Staff respond to the code including Employee # 10, who uses a non-approved NVCI hold on Patient # 11 and does not coordinate their physical restraint attempt with Employee # 11, leading to Patient # 11 falling to the ground and breaking free of the physical restraint. A review of the facility document "Incident Report: ASH-2023-2299" revealed "...(Patient # 11) approached him and placed his hands around (Patient # 5's) throat, and started choking him...Several staff arrived on the scene and assisted with separating (Patient # 11) and (Patient # 4)...." The "Incident Report: ASH-2023-2299" fails to mention the fall to the ground by Patient # 11 after the initial attempted physical restraint. A review of the "Incident Report: ASH-2023-2299" revealed two quality management reviews on May, 30, 2023 with both had "...No recommendations..." followed by a supervisor review on June 6, 2023 and an additional review by social work on June 16, 2023 which both also determined "...No recommendations..." A review of the medical records of Patient # 4 and Patient # 11 on March 29, 2024, revealed evidence of progress notes, seclusion and restraint logs and nursing assessments regarding the incident on May 26, 2023 between the two patients. A review of the seclusion and restraint log for Patient # 11 dated May 26, 2023 revealed "...(Patient # 11) reported pain his left shoulder and elbow. (Patient # 11) was sent to Valleywise ED for further evaluation as a precaution...." A review of a progress notes for Patient # 11 dated May 26, 2023 revealed "...Resident reported injuries sustained from his continued struggling against a code gray...restraint that required multiple staff to control him...guarding/pain at his left shoulder and elbow....He will be sent to the ER this evening for evaluation...." Employee # 1 confirmed in an interview on March 28, 2024, that Patient # 11 was sent to the emergency room for an evaluation on May 26, 2023 and returned on May 27, 2023.


summary: Complaint - 11/13/2023 - 11/15/2023

raw_content: No deficiencies were cited at the time of the unannounced desktop State Complaint Investigation survey, Event # FPSL11 conducted on November 13, 2023, through November 15, 2023, pursuant to the rules found in 9 A.A.C. 10 - Article 13: Behavioral Health Specialized Transitional Facility, for the following intakes: AZ00202637 Christine D. Pereira, PsyD Healthcare Compliance Surveyor


summary: Complaint - 10/12/2023 - 10/24/2023

raw_content: No deficiencies were cited at the time of the unannounced, State Complaint Investigation survey, Event # 1GOR11 conducted on October 12, 2023 through October 24, 2023, pursuant to the rules found in 9 A.A.C. 10 - Article 13: Behavioral Health Specialized Transitional Facility, for the following intakes: AZ00193587 AZ00193591 AZ00193309 AZ00191658 AZ00193163 AZ00193597 AZ00194492 AZ00194377 AZ00193585 AZ00193586 AZ00193588 Ted Murphy Connie Martinez Healthcare Compliance Surveyors October 24, 2023


facility_name: NEW HOPE OF ARIZONA, INC

summary: Compliance (Annual) - 7/18/2025

raw_content: No deficiencies were found during the on-site compliance inspection conducted on July 18, 2025.

inspection_type: Compliance (Annual)


summary: Compliance (Annual) - 7/15/2024

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on July 15, 2024:

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

evidence: Based on record review and interview, the administrator failed to ensure a resident was admitted based upon the resident's primary condition being a behavioral health issue, for two of three residents sampled who's primary condition was not a behavioral health issue. The deficient practice posed a risk if R1's primary condition was a physical health issue.

findings: R9-10-101.32. "Behavioral health issue" means an individual's condition related to a mental disorder, a personality disorder, substance abuse, or a significant psychological or behavioral response to an identifiable stressor or stressors. 1. A review of Department documentation revealed BH6883 was licensed as a Behavioral Health Residential Facility authorized to provide respite services. 2. A review of facility documentation revealed a policy and procedure titled "Scope of Service." The policy and procedure stated, "Behavioral Health Residential Services provides a structured treatment setting with 24 hour supervision and counseling or other therapeutic activities for members who do not require on site medical services, under the supervision of an on call behavioral health professional...." 3. A review of R1's medical record revealed an Integrated Service Plan dated August 15, 2023. The Service Plan stated "R1 will have a DSP referral sent in to request high needs case management services. R1 will have a DSP referral sent in to request DDD services... The Clinician recommends case management, CFT's, PCP and dental services yearly. Individual counseling and natural support from family. As well as psych evaluation, nursing assessment and medication management. The Clinician will also recommend a DSP referral for high needs case management, community resources for DDD services, and behavioral coaching in the community." 4. A review of R1's medical record revealed a Southwest Behavioral Health Services Assessment reflecting the following diagnoses; Attention-deficit hyperactivity disorder and Autistic Disorder dated 2023. 5. A review of R1's medical record revealed a behavioral health assessment (dated February 8, 2023). The assessment was conducted within twelve months of R1's admission and reviewed by the facility on January 26, 2024. A summary note of R1's behavioral health assessment completed by the facilities BHP reflected the following information; "Member does not like taking morning medications and needs visual confirmation [R1] swallowed meds. Member does not like to be touched by others. Member does not like to eat, only eats what [R1] likes snacks. Member has ran out of the home when upset in the past. Member struggles manipulating others and lying to get way. Member will steal, barter and trade." 6. A review of R1's medical record revealed a document titled "Case Management Progress Note." conducted by the residential facility. The note reflected "Diagnoses Codes Autistic Disorder" dated February 15, 2024. The note reflected no additional codes. 7. A review of R1's medical record revealed a Southwest Behavioral Health Services note dated March 20, 2024. The note reflected "Presenting Concerns: The concerns for [R1] are intense, compulsive behaviors that affect [R1's] current and possible future self.. .Concerned that [R1] does things that are harmful to others (lying, stealing, being aggressive verbally and physically). Also, for medication management services to continue....Risk Assessment The last time [R1] harmed/injured someone intentionally was two weeks ago. [R1] will try to punch, hurt [R1's] [sibling]; recently threw a rock at [sibling] while upset. [R1] kicked [Grandparent] in the eye recently....[R1] is referred by DCS to continue services. [R1] has received individual animal assisted therapy, medication management, behavior coaching intake, high needs care coordination, a psychological evaluation. [R1] experiences mood dis-regulation, anger towards others and physical aggression towards others. [R1] is diagnosed with Attention-deficit hyperactivity disorder,combined type - F90.2 and Autistic disorder - F84.0 (SACE evaluation 11/18/22 completed by... : "Due to deficits in verbal and nonverbal social communication, social-emotional reciprocity, and in developing, maintaining and understanding relationships causing impairments in functioning, meets criteria for level 1, in the social communication and social interaction domain. Due to insistence on sameness, difficultly with transitions, inflexible thinking, highly restricted and fixated, nonsocial interests that are abnormal, and hypersensitivity to sensory input causing impairment in functioning") It is recommended that [R1] receive medication management, psychiatric evaluations yearly, RN assessments as needed, high needs care coordination, respite and MMWIA behavior coaching services." 8. In an interview, E1 reported E1 believed R1's diagnosis was a behavioral health diagnosis. E1 acknowledged R1's medical record reflected the identified diagnoses and concerns. E1 reported E1 believed R1 was appropriate for respite services offered with no behavioral issues during respite services. E1 acknowleged R1's medical record reflected a resident was not admitted based on the resident's primary condition for which the resident was admitted was a behavioral health issue.


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

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on June 26, 2023:

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

evidence: Based on record review and interview, the administrator failed to ensure if a medical practitioner performed a medical history and physical examination or a nurse performed a nursing assessment on a resident before admission, the medical practitioner entered an interval note or the nurse entered a progress note in the resident's medical record within seven calendar days after admission, for one of two residents sampled.

findings: 1. A review of R2's medical record revealed a physical and medical history completed before admission. R2's medical record did not contain evidence the medical practitioner entered an interval note or the nurse entered a progress note in the resident's medical record within seven calendar days after admission. 2. In an interview, E1 reviewed R2's medical record. E1 acknowledged the medical record did not contain evidence the medical practitioner entered an interval note or the nurse entered a progress note in the resident's medical record within seven calendar days after admission.

rule: A. An administrator shall ensure that: 5. Behavioral health services listed in the behavioral health residential facility's scope of services are provided on the premises;

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure behavioral health services listed in the behavioral health residential facility's scope of services were provided on the premises.

findings: 1. A review of the facility policies and procedures reviewed July 1, 2020, revealed a scope of services. The scope of services stated, "...Behavioral Health Residential Services provides a structured treatment setting with twenty four hour supervision and counseling..." 2. A review of R1 and R2's treatment plans revealed no documentation of counseling identified in the residents medical record. 3. In an interview, E1 reported the identified facility residents receive respite services. E1 acknowledged the facility is licensed as a behavioral health residential facility. E1 acknowledged the behavioral health services listed in the behavioral health residential facility's scope of services were not provided on the premises.


facility_name: SAHARAN OASIS

summary: Complaint;Compliance (Annual) - 9/16/2025

raw_content: The following deficiencies were found during the on-site compliance inspection and investigation of complaint 00127831 conducted on September 16, 2025:

inspection_type: Complaint;Compliance (Annual)

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

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of the individual's completed orientation as required by policies and procedures, for one of five sampled personnel members. The deficient practice posed a safety risk if E2 were unable to meet the needs of the residents.

findings: 1. Arizona Administrative Code (A.A.C.) R9-10-101.155. states "Orientation" means "the initial instruction and information provided to an individual before the individual starts work or volunteer services in a health care institution." 2. A review of facility documentation revealed a policy and procedure titled "Policy Review and Trainings" dated July 6, 2022. The policy stated "...All personnel, volunteers and contractors are required to attend orientation prior to starting at Saharan Oasis to review program guidelines, policies and procedures." 3. A review of E2's personnel record revealed E2 had no documentation of a completed orientation. 4. In an interview, E1 reported E2 completed orientation for the facility; however, E1 did not document the completed orientation. 5. In an exit interview, the findings were reviewed with E1, and no further documentation or comments were provided.

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

evidence: Based on record review and interview, the administrator failed to ensure a personnel record was maintained for each personnel member which included documentation of the individual's compliance with the requirements in A.R.S. § 8-804, for one of five personnel records sampled. The deficient practice posed a safety risk as the Department was unable to determine substantial compliance.

findings: A.R.S. § 8-804(K) states "Before being employed in a position that provides direct services to children or vulnerable adults pursuant to subsection B, paragraphs 4, 5 and 10 and 11 or subsections C and D and E of this section, employees shall certify, under penalty of perjury, on forms that are provided by the department whether an allegation of abuse or neglect was made against them and was substantiated. The forms are confidential. If this certification does not indicate a current investigation or a substantiated report of abuse or neglect, the employee may provide direct services pending the findings of the central registry check." 1. A review of E2's personnel record revealed no documentation demonstrating the licensee submitted to the Department of Child Safety in a manner prescribed by the Department of Child Safety, information necessary to conduct a central registry background check on E2. 2. In an interview, E1 reported being unaware of the requirement. E1 reported E2 was an on-call personnel member. 3. In an exit interview, the findings were reviewed with E1, and no further documentation or comment was provided.


summary: Complaint - 2/20/2025

raw_content: An on-site investigation of complaint 00116030 was conducted on February 20, 2025 and the following deficiencies were cited:

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

evidence: Based on record review and interview, the administrator failed to ensure documentation of current contracted services was maintained to include a description of the contracted services provided.

findings: 1. A review of E2's (hired in 2023) personnel record revealed E2 was hired as the behavioral health professional. The personnel record revealed documentation of contracted services. The document stated ".... Behavioral Health Professional Contract UPDATED 4.26.23 This Agreement shall begin on 10.1.22 to 10.1.23 …” 2. In an interview, E1 reported the aforementioned document was the only document available for review. 3. In an interview, E6 stated E2 was a “1099” employee. 4. In a joint exit interview, the findings were reviewed with E1 and E6 and no additional comments, statements, or documentation were provided regarding the findings.

rule: R9-10-706.K.3.a. Personnel 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 documentation review and interview, the administrator failed to ensure there was a daily staffing schedule to indicate the scheduled work hours, and name of each employee assigned to work, including on-call personnel members. The deficient practice posed a risk if there was no record to ensure shifts and tasks were covered.

findings: 1. A review of facility documentation revealed a daily staffing schedule for January 26, 2025-February 1, 2025 and February 9-22, 2025. However, the daily staffing schedules did not include the behavioral health professional and registered nurse as on-call personnel members. 2. A review of the aforementioned schedules revealed E2 (the behavioral health professional) was scheduled as “OFF.” 3. In an interview E6 reported E2 and E3 (the registered nurse) were on-call. 4. In a joint exit interview, the findings were reviewed with E1 and E6 and no additional comments or statements were provided regarding the findings.

rule: R9-10-708.A.4.b. Treatment Plan A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that: 4. Includes: b. The physical health services or behavioral health services to be provided to the resident;

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a treatment plan was developed for each resident to include the frequency and number of hours of behavioral health services to be provided to the resident per R9-10-716(B)(2), for two of two residents sampled. The deficient practice posed a risk as a treatment plan was not developed to articulate decisions and agreements of services to be provided.

findings: 1. A review of facility documentation revealed a scope of services (dated July 6, 2022). The scope of services stated "... Saharan Oasis offers individual therapy, group therapy, … family counselling …” 2. A review of R1's (admitted in 2024) medical record revealed a treatment plan (dated in 2025). However, the treatment plan did not include the frequency and number of hours of behavioral health services to be provided to R1. 3. A review of R1’s medical record revealed documentation of individual counseling sessions provided once a week for approximately fifty (50) minutes each. 4. A review of R2's (admitted in 2024) medical record revealed a treatment plan (dated in 2025). However, the treatment plan did not include the frequency and number of hours of behavioral health services to be provided to R2. 5. A review of R2’s medical record revealed documentation of individual counseling sessions provided once a week for approximately fifty (50) minutes each. 6. In an interview, E6 reported all residents only receive individual counseling once a week. 7. In a joint exit interview, the findings were reviewed with E1 and E6 and no additional comments, statements, or documentation were provided regarding the findings.

rule: R9-10-721.A.1.c. Environmental Standards A. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 1. The premises and equipment are: c. Free from a condition or situation that may cause a resident or other individual to suffer physical injury;

evidence: Based on observation and interview, the administrator failed to ensure the facility was free from a condition or situation to cause a resident or other individual to suffer physical injury. The deficient practice posed a tripping hazard to the residents.

findings: 1. The Compliance Officer observed an unraveled garden hose in the backyard patio. 2. The Compliance Officer observed a hole in the backyard next to the patio. The hole appeared to be dug-up and appeared to be approximately one foot in diameter. The Compliance Officer observed footwear impressions all around the dirt near the hole. 3. In a joint exit interview, the findings were reviewed with E1 and E6 and no additional comments or statements were provided regarding the findings.


summary: Compliance (Annual) - 9/3/2024

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on September 3, 2024.

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

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of cardiopulmonary resuscitation (CPR) training, if required for the individual according to R9-10-703(C)(1)(e), for two of four personnel sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency, and the documentation was not provided within two hours after a Department request.

findings: 1. A review of the facility's policies and procedures revealed a policy titled "CPR/First Aid" dated in 2022. The policy stated "CPR and First Aid Standards Only accept CPR trainings from American Safety and Health Institute (ASHI) or American Heart Association...Trainings must include Hands-On training where demonstration to perform CPR can occur prior to receiving certification. All staff, contractors, and volunteers must possess current certification and a copy of the certificate(s) are in their training file." 2. A review of the facility's staffing schedule revealed E3 was the only staff expected to work from 10:00 pm-10:00 am shift on September 6, 2024. 3. A review of the facility's staffing schedule revealed E4 was the only staffing working from 6:00 pm-10:00 pm shift on September 2, 2024. 4. A review of E3's personnel record revealed documentation of current CPR training dated July 12, 2023, from "NationalCPRFoundation". The document stated "Valid for 2 years" 5. A review of E4's personnel record revealed documentation of current CPR training dated February 9, 2023, from "NationalCPRFoundation". The document stated "Valid for 2 years" 6. A review of the "nationalcprfoundation.com" website revealed the following statement: "National CPR Foundation is known for providing Life-Skill Techniques for longer more lasting lives. Harness the Power of Our Online Training and Earn Your Certification Today - The Smarter Way." 7. In an interview, E1 acknowledged CPR and first aid for E3 and E4 was completed online.

rule: A. An administrator shall ensure that: 6. Except as provided in subsection (E)(1)(a), a medical practitioner performs a medical history and physical examination or a registered nurse performs a nursing assessment on a resident within 30 calendar days before admission or within 72 hours after admission and documents the medical history and physical examination or nursing assessment in the resident's medical record within 72 hours after admission;

evidence: Based on record review and interview, the administrator failed to maintain documentation of registered nurse who performed a nursing assessment on a resident within 30 calendar days before admission or within 72 hours after admission, for two of two residents sampled. The deficient practice posed a risk as this information was required for the development and implementation of a treatment plan, per R9-10-708.A.1.

findings: 1. A review of R1's medical record revealed a nursing assessment dated in August 2024. The document contained a nursing assessment for R1. However, the document did not contain a signature from the registered nurse who performed the assessment. 2. A review of R2's medical record revealed a nursing assessment dated in August 2024. The document contained a nursing assessment for R2. However, the document did not contain a signature from the registered nurse who performed the assessment. 3. In an interview, E1 acknowledged R1's and R2's nursing assessments did not include the signature of the individual who performed the nursing assessment.


summary: Complaint - 3/12/2024

raw_content: An on-site investigation of a complaint was conducted on March 12, 2024 and the following deficiencies were cited :

rule: C. An administrator shall ensure that: 1. Policies and procedures are established, documented, and implemented to protect the health and safety of a resident that: a. Cover job descriptions, duties, and qualifications, including required skills, knowledge, education, and experience for personnel members, employees, volunteers, and students;

evidence: Based on documentation review, record review, and interview, the administrator failed to establish and document policies and procedures to protect the health and safety of a resident to cover job descriptions. The deficient practice posed a health and safety risk to the residents.

findings: 1. A review of the facility's documentation revealed an incident report dated March 4, 2024. The incident report stated "On 03/04/2024 at approximately 2000 hrs BHT [E4] instructed [R1] and [R1's] peers that it was currently bedtime and to report to their living quarters. [R1] and [R1's] peers did comply with the request. BHT [E4] was sitting in the office area and a peer came back downstairs after approximately 5 mins of being in the room and stated that [R1] struck [R2] in the face with a close fist due to the peer turning the bathroom light off. BHT went to the living quarters and asked [R1] about the alleged incident. [R1] did not respond and did not engage with staff. BHT proceeded to inform all peers that it was currently bedtime and turned the light off. BHT sat in the doorway of the room to ensure no other incidents took place. [R1] continued to sit on [R1's] bed and after a few minutes [R1] was observed with something in [R1's] hand. Due to it being dark staff was unsure of the object and asked [R1] what was currently in [R1's] hand. [R1] responded with "it's a shank and I'm going to use it on [R2]". Staff immediately turned the light on and asked [R1] to give [E4] the object. [R1] had [R1's] hands behind [R1's] back and after multiple requests to give the object to staff, [R1] refused. As staff approached [R1], [R1] was observed attempting to run at [R1's] peer with the object, that was observed to be a pen, and BHT had to place [R1] in a therapeutic hold for DTO. While in the therapeutic hold staff were able to take the pen from [R1] and then proceeded to release the therapeutic hold. Once released [R1] immediately began to throw all [R1's] peers clothing and personal property all over the room. [R1] picked up the plastic dresser in the room and threw it at staff, striking the staff member. After several verbal commands for [R1] to disengage in [R1's] current physical aggression [R1] refused to comply. [R1] walked toward the peer [R1] was alleged to hit earlier and started to strike the peer in the head and back area with a closed fist. Staff immediately placed [R1] back into a therapeutic hold. While in the therapeutic hold bit staff on [E4's] wrist area and attempted to headbutt [E4] multiple times. [R1] remained in the therapeutic hold for approximately 7 mins and once [R1] was deemed to be no longer a threat staff released the hold. BHT [E4] remained standing next to [R1] until a secondary staff arrived within a few minutes. Admin [E1] arrived and was able to get [R1] to agree to go to [facility name] to be evaluated..." 2. A review of the facility's policies and procedures revealed a policy titled "BEHAVIORAL HEALTH TECHNICIAN JOB DESCRIPTION" dated July 6, 2022. The policy stated "Skills: Demonstrate strong professional boundaries Excellent written and verbal communication skills Must be able to work in and foster a culturally diverse environment Must be able to maintain order and structure Shows a concern and empathy towards children in trouble Capable of following directives." However, the policies and procedures were not established and documented to include the use of an emergency safety response for BHT's. 3. A review of E4's personnel record revealed a current crisis prevention intervention training card with an expiration date of November 20, 2024. 4. In an interview, E1 acknowledged policies and procedures were not established and documented to cover job descriptions to include the use of emergency safety responses for BHT's.

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: 2. Report the suspected abuse, neglect, or exploitation of the resident: b. For a resident under 18 years of age, according to A.R.S. § 13-3620;

evidence: Based on documentation review and interview, the administrator failed to report suspected abuse, neglect, or exploitation of a resident under 18 years of age according to A.R.S. \'a7 13-3620. The deficient practice posed a health and safety to residents as the facility had a reasonable basis to believe abuse had occurred on the premises, and it was not reported per A.R.S. \'a7 13-3620. The deficient practice posed a health and safety risk to the residents.

findings: 1. A.R.S. \'a7 13-3620.A states "A. Any person who reasonably believes that a minor is or has been the victim of physical injury, abuse, child abuse, a reportable offense or neglect that appears to have been inflicted on the minor by other than accidental means or that is not explained by the available medical history as being accidental in nature or who reasonably believes there has been a denial or deprivation of necessary medical treatment or surgical care or nourishment with the intent to cause or allow the death of an infant who is protected under section 36-2281 shall immediately report or cause reports to be made of this information to a peace officer, to the department of child safety or to a tribal law enforcement or social services agency for any Indian minor who resides on an Indian reservation, except if the report concerns a person who does not have care, custody or control of the minor, the report shall be made to a peace officer only..." 2. Arizona Administrative Code (A.A.C.) R9-10-101(110) states "Immediate" means "without delay." 3. A review of the facility's documentation revealed an incident report dated March 4, 2024. The incident report stated "On 03/04/2024 at approximately 2000 hrs BHT [E4] instructed [R1] and [R1's] peers that it was currently bedtime and to report to their living quarters. [R1] and [R1's] peers did comply with the request. BHT [E4] was sitting in the office area and a peer came back downstairs after approximately 5 mins of being in the room and stated that [R1] struck [R2] in the face with a close fist due to the peer turning the bathroom light off. BHT went to the living quarters and asked [R1] about the alleged incident. [R1] did not respond and did not engage with staff. BHT proceeded to inform all peers that it was currently bedtime and turned the light off. BHT sat in the doorway of the room to ensure no other incidents took place. [R1] continued to sit on [R1's] bed and after a few minutes [R1] was observed with something in [R1's] hand. Due to it being dark staff was unsure of the object and asked [R1] what was currently in [R1's] hand. [R1] responded with "it's a shank and I'm going to use it on [R2]". Staff immediately turned the light on and asked [R1] to give [E4] the object. [R1] had [R1's] hands behind [R1's] back and after multiple requests to give the object to staff, [R1] refused. As staff approached [R1], [R1] was observed attempting to run at [R1's] peer with the object, that was observed to be a pen, and BHT had to place [R1] in a therapeutic hold for DTO. While in the therapeutic hold staff were able to take the pen from [R1] and then proceeded to release the therapeutic hold. Once released [R1] immediately began to throw all [R1's] peers clothing and personal property all over the room. [R1] picked up the plastic dresser in the room and threw it at staff, striking the staff member. After several verbal commands for [R1] to disengage in [R1's] current physical aggression [R1] refused to comply. [R1] walked toward the peer [R1] was alleged to hit earlier and started to strike the peer in the head and back area with a closed fist. Staff immediately placed [R1] back into a therapeutic hold. While in the therapeutic hold bit staff on [E4's] wrist area and attempted to headbutt [E4] multiple times. [R1] remained in the therapeutic hold for approximately 7 mins and once [R1] was deemed to be no longer a threat staff released the hold. BHT [E4] remained standing next to [R1] until a secondary staff arrived within a few minutes. Admin [E1] arrived and was able to get [R1] to agree to go to [facility name] to be evaluated..." However, the electronic document did not include documentation of the reporting requirements according to A.R.S. \'a7 13-3620. 4. In an interview, The Compliance Officer asked E1 if the incident that occurred on March 4, 2024 involving R1 and R2 had been reported according to A.R.S. \'a7 13-3620. E1 reported the incident had not been reported per A.R.S. \'a7 13-3620. E1 acknowledged the incident that occurred on March 4, 2024 involving R1 and R2 had not been reported according to A.R.S. \'a7 13-3620.

rule: B. An administrator shall ensure that: 2. A resident is not subjected to: i. Restraint;

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a resident was not subjected to restraints. The deficient practice posed a health and safety risk to the residents.

findings: 1. Arizona Administrative Code (A.A.C.) R9-10-101(199)" "Restraint" means any physical or chemical method of restricting a patient's freedom of movement, physical activity, or access to the patient ' s own body." 2. A review of the facility's documentation revealed an incident report dated March 4, 2024. The incident report stated "On 03/04/2024 at approximately 2000 hrs BHT [E4] instructed [R1] and [R1's] peers that it was currently bedtime and to report to their living quarters. [R1] and [R1's] peers did comply with the request. BHT [E4] was sitting in the office area and a peer came back downstairs after approximately 5 mins of being in the room and stated that [R1] struck [R2] in the face with a close fist due to the peer turning the bathroom light off. BHT went to the living quarters and asked [R1] about the alleged incident. [R1] did not respond and did not engage with staff. BHT proceeded to inform all peers that it was currently bedtime and turned the light off. BHT sat in the doorway of the room to ensure no other incidents took place. [R1] continued to sit on [R1's] bed and after a few minutes [R1] was observed with something in [R1's] hand. Due to it being dark staff was unsure of the object and asked [R1] what was currently in [R1's] hand. [R1] responded with "it's a shank and I'm going to use it on [R2]". Staff immediately turned the light on and asked [R1] to give [E4] the object. [R1] had [R1's] hands behind [R1's] back and after multiple requests to give the object to staff, [R1] refused. As staff approached [R1], [R1] was observed attempting to run at [R1's] peer with the object, that was observed to be a pen, and BHT had to place [R1] in a therapeutic hold for DTO. While in the therapeutic hold staff were able to take the pen from [R1] and then proceeded to release the therapeutic hold. Once released [R1] immediately began to throw all [R1's] peers clothing and personal property all over the room. [R1] picked up the plastic dresser in the room and threw it at staff, striking the staff member. After several verbal commands for [R1] to disengage in [R1's] current physical aggression [R1] refused to comply. [R1] walked toward the peer [R1] was alleged to hit earlier and started to strike the peer in the head and back area with a closed fist. Staff immediately placed [R1] back into a therapeutic hold. While in the therapeutic hold bit staff on [E4's] wrist area and attempted to headbutt [E4] multiple times. [R1] remained in the therapeutic hold for approximately 7 mins and once [R1] was deemed to be no longer a threat staff released the hold. BHT [E4] remained standing next to [R1] until a secondary staff arrived within a few minutes. Admin [E1] arrived and was able to get [R1] to agree to go to [facility name] to be evaluated..." 3. A review of E4's personnel record revealed current crisis prevention intervention (CPI) training. 4. In an interview, E1 reported the incident report was not accurate. E1 reported E4 had R1 in a therapeutic hold for no longer than five minutes. E1 acknowledged the incident report stated R1 was in a therepeuitc hold for approximately seven minutes. E1 acknowledged the prolonged therapeutic hold R1 was placed in could be considered a restraint.

rule: E. An administrator shall ensure that: 1. An emergency safety response is: b. Discontinued at the earliest possible time, but no longer than five minutes after the emergency safety response is initiated;

evidence: Based on record review, the administrator failed to ensure that an emergency safety response was discontinued at the earliest possible time, but no longer than five minutes after the emergency safety response was initiated. The deficient practice posed a health and safety risk to the residents.

findings: 1. A review of the facility's documentation revealed an incident report dated March 4, 2024. The incident report stated "On 03/04/2024 at approximately 2000 hrs BHT [E4] instructed [R1] and [R1's] peers that it was currently bedtime and to report to their living quarters. [R1] and [R1's] peers did comply with the request. BHT [E4] was sitting in the office area and a peer came back downstairs after approximately 5 mins of being in the room and stated that [R1] struck [R2] in the face with a close fist due to the peer turning the bathroom light off. BHT went to the living quarters and asked [R1] about the alleged incident. [R1] did not respond and did not engage with staff. BHT proceeded to inform all peers that it was currently bedtime and turned the light off. BHT sat in the doorway of the room to ensure no other incidents took place. [R1] continued to sit on [R1's] bed and after a few minutes [R1] was observed with something in [R1's] hand. Due to it being dark staff was unsure of the object and asked [R1] what was currently in [R1's] hand. [R1] responded with "it's a shank and I'm going to use it on [R2]". Staff immediately turned the light on and asked [R1] to give [E4] the object. [R1] had [R1's] hands behind [R1's] back and after multiple requests to give the object to staff, [R1] refused. As staff approached [R1], [R1] was observed attempting to run at [R1's] peer with the object, that was observed to be a pen, and BHT had to place [R1] in a therapeutic hold for DTO. While in the therapeutic hold staff were able to take the pen from [R1] and then proceeded to release the therapeutic hold. Once released [R1] immediately began to throw all [R1's] peers clothing and personal property all over the room. [R1] picked up the plastic dresser in the room and threw it at staff, striking the staff member. After several verbal commands for [R1] to disengage in [R1's] current physical aggression [R1] refused to comply. [R1] walked toward the peer [R1] was alleged to hit earlier and started to strike the peer in the head and back area with a closed fist. Staff immediately placed [R1] back into a therapeutic hold. While in the therapeutic hold bit staff on [E4's] wrist area and attempted to headbutt [E4] multiple times. [R1] remained in the therapeutic hold for approximately 7 mins and once [R1] was deemed to be no longer a threat staff released the hold. BHT [E4] remained standing next to [R1] until a secondary staff arrived within a few minutes. Admin [E1] arrived and was able to get [R1] to agree to go to [facility name] to be evaluated..." 2. In an interview, E1 reported the incident report was not accurate. E1 reported E4 had R1 in a therapeutic hold for no longer than five minutes. E1 acknowledged the incident report stated R1 was in a therepeuitc hold for approximately seven minutes.

rule: E. An administrator shall ensure that: 2. Within 24 hours after an emergency safety response is used for a resident, the following information is entered into the resident medical record: c. The specific emergency safety response used;

evidence: Based on record review and interview, the administrator failed to ensure within 24 hours after an emergency safety response was used for a resident, the specific emergency safety response used was entered into the resident medical record. The deficient practice posed a health and safety risk to the residents.

findings: 1. A review of the facility's documentation revealed an incident report dated March 4, 2024. The incident report stated "On 03/04/2024 at approximately 2000 hrs BHT [E4] instructed [R1] and [R1's] peers that it was currently bedtime and to report to their living quarters. [R1] and [R1's] peers did comply with the request. BHT [E4] was sitting in the office area and a peer came back downstairs after approximately 5 mins of being in the room and stated that [R1] struck [R2] in the face with a close fist due to the peer turning the bathroom light off. BHT went to the living quarters and asked [R1] about the alleged incident. [R1] did not respond and did not engage with staff. BHT proceeded to inform all peers that it was currently bedtime and turned the light off. BHT sat in the doorway of the room to ensure no other incidents took place. [R1] continued to sit on [R1's] bed and after a few minutes [R1] was observed with something in [R1's] hand. Due to it being dark staff was unsure of the object and asked [R1] what was currently in [R1's] hand. [R1] responded with "it's a shank and I'm going to use it on [R2]". Staff immediately turned the light on and asked [R1] to give [E4] the object. [R1] had [R1's] hands behind [R1's] back and after multiple requests to give the object to staff, [R1] refused. As staff approached [R1], [R1] was observed attempting to run at [R1's] peer with the object, that was observed to be a pen, and BHT had to place [R1] in a therapeutic hold for DTO. While in the therapeutic hold staff were able to take the pen from [R1] and then proceeded to release the therapeutic hold. Once released [R1] immediately began to throw all [R1's] peers clothing and personal property all over the room. [R1] picked up the plastic dresser in the room and threw it at staff, striking the staff member. After several verbal commands for [R1] to disengage in [R1's] current physical aggression [R1] refused to comply. [R1] walked toward the peer [R1] was alleged to hit earlier and started to strike the peer in the head and back area with a closed fist. Staff immediately placed [R1] back into a therapeutic hold. While in the therapeutic hold bit staff on [E4's] wrist area and attempted to headbutt [E4] multiple times. [R1] remained in the therapeutic hold for approximately 7 mins and once [R1] was deemed to be no longer a threat staff released the hold. BHT [E4] remained standing next to [R1] until a secondary staff arrived within a few minutes. Admin [E1] arrived and was able to get [R1] to agree to go to [facility name] to be evaluated..." However, the document did not include the specific emergency safety response used by E4. 2. In an interview, E1 acknowledged the specific emergency safety response used was not entered into R1's medical record.

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

evidence: Based on observation and interview, the administrator failed to ensure the premises was free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a health and safety risk to the residents.

findings: 1. The Compliance Officer observed a master bedroom shared by R3 and R4. The shared bedroom contained a bathroom, the bathroom contained a grab bar attached to the wall of the shower. 2. The Compliance Officer observed a hallway bathroom. The bathroom contained one grab bar attached to the wall in the shower. 3. In an interview, E1 acknowledged the grab bars posed a potential ligature hazard, and the premises was not free from a condition or situation that may cause a resident or other individual to suffer physical injury.


summary: Complaint;Compliance (Annual) - 10/12/2023

raw_content: This revised Statement of Deficiencies supersedes the previous Statement of Deficiencies for event ID MQUB11. The following deficiencies were found during the on-site compliance inspection and investigation of complaints AZ00191333, AZ00191785, and AZ00200448 conducted on October 12, 2023:

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

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

findings: 1. A review of facility documentation revealed an incident report dated September 26, 2023. The report stated "Client's Name: [R7]... Type of incident:...Self-harm...Other: Aggression towards peer...Incident: On 9-26-2023 [R7] arrived home from school in a bad mood...Once we started therapy [R7] kept saying [R7] could not do it. I encouraged [R7] that [R7] could. A peer made a statement that [R7] was doing it wrong, and [R7] started hitting [R7's] head on the wall..." 2. A review of facility documentation revealed an incident report dated September 28, 2023. The report stated "Client's Name: [R7]... Type of incident:...other: Self-harm...Incident: On 9/28/2023, approximately 2:55 pm, Lead BHT was preparing to give [R7] afternoon snack when [E2] observed bite and scratch marks on [R7's] arms...At approximately 3pm, [E2] spoke with [O4] to request a crisis team to come to the facility...[R7] was observed digging at the grout and received redirection from [E2]. [R7] began to bang [R7's] head on the wall...At approximately 4:03 pm, [E2] observed [R7] biting [R7's] knuckles then checking for marks...At around 4:22 pm is when the crisis mobile team arrived. BHT provided the team with background information before they spoke with [R7]. The team met with [R7] for approximately an hour, then deliberated...Lead BHT transported [R7] to [facility name] after recommendation from the mobile crisis team for evaluation" 3. A review of facility documentation revealed an incident report dated September 30, 2023. The report stated "Client's Name: [R6]...Incident: On 9/30/2023, around 11:00 am [R6] asked staff if [R6] could talk about [R6] losing a point earlier in the morning. Staff did advise [R6] yes; [R6] did lose the point, which makes [R6] ineligible to play the video game. [R6] instantly got trigger and started to scratch [R6's] neck until it started to bleed." 4. A review of Department documentation revealed written notification of the three aforementioned incidents were not received by the Department. 5. In an interview, E1 acknowledged E1 failed to provide written notification to the Department, within two working days after a resident inflicted a self-injury.

rule: K. An administrator shall: 9. Evaluate and take action related to unauthorized absences under the quality management program in R9-10-704.

evidence: Based on documentation review and interview, the administrator failed to evaluate and take action related to unauthorized absences under the quality management program in Arizona Administrative Code (A.A.C.) R9-10-704.

findings: 1. A review of the facility's policies and procedures revealed a policy titled "Quality Management: Section 700" dated July 6, 2022. The policy stated: "C. Data Collection a. The Manager/Administrator or Designee shall document monthly: 1) Number/type of incidents; Patterns across residents. 2) Number of residents experiencing rapid weight loss or excessive gain. 3) Number of residents with reported relapses. 4) Number of individuals referred to higher level of care 5) Number of residents referred to lower level of care 6) Number of residents reporting the loss of personal property/clothing. 7) Number of errors in the documentation of medication(MARs), treatments, ADLs, etc. provided to residents...The Administrator or Designee shall evaluate collected data quarterly to identify trends and concerns of service delivery as follows: a. Monthly meetings between the Administrator or designees, the Behavior Professional, Quality Management Personnel, and/or, behavioral health technicians, and others as needed, to discuss each month's findings and any identified trends. b. Maintain a bar graph for each of the above data collections to identify trends from quarter to quarter. c. Complete Corrective Action/Plan for trends or significant findings as needed." 2. A review of facility documentation revealed a document titled "Incident report" dated June 19, 2023. The incident report stated "On 6-19-2023 at approximately 1916 hrs BHT [E4] was currently assisting a Resident in the living room area, when [E4] observed [R1] and another peer [R4] running down the facility stairs. BHT [E4] observed [R1] with multiple layers of clothing on, water bottle and attempting to open the front door. Staff instructed [R1] and the other peer to get away from the front door and both residents ran out of the front of the facility." 3. The Compliance Officer requested to review the facility's quality management program per A.A.C. R9-10-704. However, a documented quality management program per A.A.C. R9-10-704 was not available for review. 4. In an interview, E1 reported R1 was found safe four days later, and R4 returned to the facility the next day. 5. E1 acknowledged E1 did not document, evaluate, and take action related to unauthorized absences under the quality management program in A.A.C. R9-10-704.

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 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 36-425.03(E), for one of three personnel members sampled. The deficient practice posed a risk if E3 was a danger to a vulnerable population.

findings: 1. A.R.S. \'a7 36-425.03(E) states "Children's behavioral health program personnel shall certify on forms that are provided by the department and notarized that they are not awaiting trial on or have never been convicted of or admitted in open court or pursuant to a plea agreement to committing any of the offenses listed in section 41-1758.03, subsection B or C in this state or similar offenses in another state or jurisdiction." 2. A review of E3's personnel record revealed E3 was hired as a behavioral health professional (BHP). E3's personnel record revealed documentation of compliance with A.R.S. \'a7 36-425.03(A). However, E3's personnel record contained a criminal history affidavit form from the Bureau of Child Care Licensing. The document was signed and dated by E3, however, the document was not notarized per A.R.S. \'a7 36-425.03(E). 3. In an interview, E1 acknowledged E3's documentation of compliance with A.R.S. \'a7 36-425.03(E) was not notarized.


facility_name: PROGRESSIVE HEALTH ALLIANCE

summary: Complaint - 8/11/2025

raw_content: An on-site investigation of complaint 00139000 was conducted on August 11, 2025, and the following deficiencies were cited:

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

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

findings: 1. A review of R2's medical record revealed a treatment plan with no signature of the resident or the resident's representative, and date signed, or documentation of the refusal to sign. 2. In an interview, E2 acknowledged R2's treatment plan did not include the resident or the resident's representative, and the date signed, or documentation of the refusal to sign. This is a repeated violation from the on-site compliance inspection conducted on February 13, 2023.

rule: R9-10-711.B.1. Resident Rights B. An administrator shall ensure that: 1. A resident is treated with dignity, respect, and consideration;

evidence: Based on observation, record review, and interview, the administrator failed to ensure that a resident was treated with dignity, respect, and consideration. The deficient practice posed a risk if R2's rights were violated.

findings: 1. The Compliance Officer observed R2 lying on a single mattress, underneath a blanket on the top of the second-floor stairs. The Compliance Officer walked around R2's mattress in the hallway to conduct the inspection. Other residents walked past R2 to gain access to their bedrooms. 2. A review of R2's medical records revealed no documentation restricting R2's personal belongings. 3. In an interview, R2 reported R2 expressed feeling depressed, and R2's mattress was therefore moved to the hallway of the facility for increased staff monitoring. R2 reported that R2 was in the hallway for two nights. 4. In an interview, E1 acknowledged placing R2 in the hallway after expressing an increase in mental health conditions, which failed to reflect that R2 was treated with dignity, respect, or consideration.

rule: R9-10-711.B.3.b. Resident Rights B. An administrator shall ensure that: 3. Except as provided in subsection (C) or (D), and unless restricted by the resident's representative, a resident is allowed to: b. Have privacy in correspondence, communication, visitation, financial affairs, and personal hygiene; and

evidence: Based on observation, record review, and interview, the administrator failed to ensure, unless restricted by the resident's representative, a resident was allowed to have privacy in correspondence, communication, visitation, financial affairs, and personal hygiene. The deficient practice posed a risk if R2's rights were violated.

findings: 1. The Compliance Officer observed cameras in the resident bedrooms and the privacy room. The Compliance Officer observed R2 receiving treatment in the facility's privacy room with cameras present at the time of the inspection. The Compliance Officer observed E1 remove all the identified cameras on site. 2. A review of R2's medical records revealed no documentation restricting residents' right to privacy in correspondence, communication, visitation, financial affairs, and personal hygiene. 3. In an interview, E1 reported E1 was unaware that E1 could not have cameras in the residents' bedrooms, as the residents perform their personal hygiene in the bathroom. E1 reported that E1 was notified of allegations of inappropriate touching occurring in the residents' bedrooms; however, E1 could not determine if the allegations were accurate. E1 acknowledged the facility had a camera visually recording in the resident's privacy room. E1 acknowledged that the residents were not provided privacy in correspondence, communication, visitation, financial affairs, and personal hygiene.

rule: R9-10-711.E.3.a. Resident Rights E. A resident has the following rights: 3. To receive privacy in treatment and care for personal needs, including the right not to be fingerprinted, photographed, or recorded without consent, except: a. A resident may be photographed when admitted to a behavioral health residential facility for identification and administrative purposes;

evidence: Based on observation and interview, the administrator failed to ensure a resident had the right to receive privacy in treatment and care for personal needs, including the right not to be fingerprinted, photographed, or recorded without consent.

findings: 1. The Compliance Officer observed video cameras in the facility's privacy room, resident bedrooms, hallways, and common spaces throughout the facility. The Compliance Officer observed E1’s phone in real time, displaying the visual recording of the privacy room. 2. In an interview, the findings were reviewed with E1, E1 removed the cameras, and no additional information or documentation was provided.


summary: Compliance (Annual) - 5/29/2025

raw_content: The following deficiency was found during the on-site compliance inspection conducted on May 29, 2025.

rule: R9-10-712.C.15. Medical Records 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 residents' medical records contained documentation of behavioral health services provided to the residents for two of two residents sampled. The deficient practice posed a risk if the Department could not verify residents received treatment to cure, improve, or palliate the residents’ behavioral health issues at the health care institution.

findings: 1. A review of R1's treatment plan revealed that the facility was to provide R1 two one-hour group counseling sessions each week, and a single one-hour individual counseling session per week. 2. A review of R2's treatment plan revealed the facility was to provide R2 two one-hour group counseling sessions each week, and a single one-hour individual counseling session per week. 3. A review of R1's medical record revealed one group counseling note. The counseling note was dated April 2025. Additionally, there were no individual counseling notes in R1's medical record. 4. A review of R2's medical record revealed documentation of two one-hour group counseling sessions each week following R2's admission. However, R2's record did not contain documentation of group counseling sessions for the month of May 2024. Additionally, there were no individual counseling notes in R2's medical record. 5. In an exit interview, E1 reported R1 and R2 each received more counseling sessions than documented in R1's and R2's medical records. However, there was no documentation of additional counseling sessions.


summary: Complaint;Compliance (Annual) - 2/28/2024

raw_content: The following deficiencies were found during the compliance inspection and investigation of complaints conducted on February 28, 2024:

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

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

findings: 1. A review of facility documentation revealed a fall prevention training program titled "Falls Policy Overview" (approval date not available). However, the training program did not include training in fall recovery and did not include the initial training and continued competency training requirement. 2. A review of E1's, E5's, and E6's personnel records revealed initial training in fall prevention. However, the initial training did not include fall recovery. 3. A review of E2's and E3's personnel records revealed initial training and continued competency training in fall prevention and fall recovery were not available for review. 4. In an interview, E1 acknowledged the facility did not administer initial training to E1, E5 and E6 in fall recovery, the facility did not administer continued competency training in fall prevention and fall recovery training E2 and E3, and did not develop initial training and continued competency training for fall recovery. This is a repeat citation from the compliance inspection conducted on February 13, 2023.

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

evidence: Based on record review and interview, the administrator failed to ensure a personnel record included the individual's starting date of employment, for one of six personnel members sampled.

findings: 1. A review of E1's personnel record revealed E1's starting date of employment was not available for review. 2. In an interview, E1 acknowledged E1's starting date of employment was not available for review.

rule: G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes: 3. Documentation of: 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 applicable to the individual's job duties, for three of six personnel records sampled.

findings: 1. A review of facility documentation revealed a policy titled "Sectional 3: Personnel" (approval date unknown). The policy stated "minimal requirements for an executive administrator are: ...minimum of an associate degree in behavioral health or any health related field...minimum requirements for a behavioral health technician/BHT are:...has an associate degree in a field related to human services; or has a high school diploma..." 2. A review of E1's personnel record revealed E1 was hired as an administrator and behavioral health technician (BHT). However, E1's education was not available for review. 3. A review of E5's and E6's personnel records revealed E5 and E6 were hired at BHTs. However, E5's and E6's education was not available for review. 4. In an interview, E1 acknowledged documentation of education for E1, E5, and E6 was not available for review.

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

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel record included documentation of the individual's completed orientation, for five of six personnel records sampled.

findings: R9-10-101(155) "Orientation" means the initial instruction and information provided to an individual before the individual starts work or volunteer services in a health care institution. 1. A review of facility documentation revealed a policy titled "Training" (approval date unknown). The policy stated "A. Orientation/Training prior to providing services include ..." 2. A review of E1's, E2's, E3's, E5's, and E6's personnel records revealed documentation of completed orientation was not available for review. 3. In an interview, E1 reported E2 completed orientation, and acknowledged orientation for E1, E2, E3, E5, and E6 was not available for review.

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

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel member that included documentation of the individual's compliance with requirements in A.R.S. \'a7 8-804, for five of six personnel members sampled.

findings: A.R.S. \'a7 8-804(C) Licensees that do not contract with the state and that employ persons who provide direct services to children pursuant to title 36, chapter 7.1 must submit to the department of child safety in a manner prescribed by the department of child safety information necessary to conduct central registry background checks. The department of health services shall verify whether licensees, pursuant to title 36, chapter 7.1, have complied with the requirements of this subsection and any rules adopted by the department of health services to implement this subsection. A.R.S. \'a7 8-804(K) Before being employed in a position that provides direct services to children or vulnerable adults pursuant to subsection B, paragraphs 4, 5 and 10 and 11 or subsections C and D and E of this section, employees shall certify, under penalty of perjury, on forms that are provided by the department whether an allegation of abuse or neglect was made against them and was substantiated. The forms are confidential. If this certification does not indicate a current investigation or a substantiated report of abuse or neglect, the employee may provide direct services pending the findings of the central registry check. 1. A review of E1's personnel record revealed E1 was hired as an administrator and behavioral health technician (BHT). The review revealed documentation demonstrating the licensee submitted to the department of child safety in a manner prescribed by the department of child safety information necessary to conduct a central registry background check on E1 was not available for review. 2. A review of E2's personnel record revealed E2 was hired as a registered nurse (RN). The review revealed documentation demonstrating the licensee submitted to the department of child safety in a manner prescribed by the department of child safety information necessary to conduct a central registry background check on E3 was not available for review. 3. A review of E3's personnel record revealed E3 was hired as a behavioral health professional (BHP). The review revealed documentation demonstrating the licensee submitted to the department of child safety in a manner prescribed by the department of child safety information necessary to conduct a central registry background check on E3 was not available for review. 4. A review of E5's and E6's personnel records revealed E5 and E6 were hired as BHTs. The review revealed documentation demonstrating the licensee submitted to the department of child safety in a manner prescribed by the department of child safety information necessary to conduct a central registry background check on E5 and E6 was not available for review. 5. In an interview, E1 confirmed the facility provided services to children. E1 reported E1 was unsure if the requirement was applicable to the facility and acknowledged the facility did not maintain documentation required in A.R.S. \'a7 8-804 in the facility's personnel records.

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

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

findings: 1. A review of R1's and R3's, medical records revealed treatment plans dated in January 2024. However, the treatment plans did not include the frequency and number of hours of counseling to be provided to R1 and R3. 2. A review of R2's and R7's medical records revealed treatment plans dated in February 2024. However, the treatment plans did not include the frequency and number of hours of counseling to be provided to R2 and R7. 3. A review of R5's medical record revealed a treatment plan dated in November 2023. However, the treatment plan did not include the frequency and number of hours of counseling to be provided to R5. 4. A review of R6's medical record revealed a treatment plan dated in December 2023. However, the treatment plan did not include the frequency and number of hours of counseling to be provided to R6. 5. In an interview, E1 acknowledged treatment plans did not include the number of hours of counseling to be provided to the residents.

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 reviewed and updated on an on-going basis according to the review date specified in the treatment plan, for one of seven residents sampled.

findings: 1.A review of R6's medical record revealed a treatment plan dated in December 2023. The treatment plan had a review date identified in January 2024. However, a review and updated treatment plan in January 2024 was not available for review. 2. In an interview, E1 acknowledged R6's treatment plan was not reviewed and updated according to the review date specified in the treatment plans.

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

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure assistance in the self-administration of medication provided to a resident was in compliance with an order, and documented in the resident's medical record, for five of seven 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, and false or misleading information was provided for R4.

findings: 1. A review of facility documentation revealed a policy titled "Medication Orders'' (approval date unknown). The policy stated "All resident medication orders must be authenticated by the medical practitioner or the BHP giving such orders. Such orders will be documented in the resident's file immediately. All orders must be provided in writing and must contain ...Signature of the professional giving the order." 2. A review of R1's medical record revealed a medication order dated in January 2024. The medication order indicated R1 was receiving assistance in the self-administration of medication for the following: -"Atomoxetine 40mg Daily"; -"Divalproex 500mg BID"; -"Guanfacine 2mg ER Daily"; -"Hydroxyzine 25mg BID";and -"Melatonin". However, the medication order was not signed by the prescribing medical practitioner. 3. A review of R1's medical record revealed a medication administration record (MAR) dated in January 2024. The MAR indicated R1 received assistance in the self-administration of the following: -Divalproex 500mg tab, take 1 tablet by mouth twice a day; -Hydroxyzine 25mg cap, tale 1 cap by mouth twice a day; and -Melatonin 5mg tab, take 1 tab by mouth at bedtime. The MAR indicated assistance in the self-administration provided to R1 for Divalproex 500mg tablet on January 13, 16, and 18, 2024 was not available for review; Hydroxyzine 25mg capsule on January 16th, 2024 was not available for review; and Melatonin 5mg tablet on January 1, 10, 11, 19, and 31, 2024 was not available for review. 4. A review of R2's medical record revealed a medication order dated in February 2024. The medication order indicated R2 was receiving assistance in the self-administration of medication for the following: -"Acidophilus caps"; -"Clonidine 0.2mg"; -"Trazadone 100mg"; -"Olanzapine 20mg"; -"Lisinopril 10mg"; -"Melatonin 5mg"; -"Cetrizine 10mg"; and -"Hydroxyzine PAM 25mg". However, the medication order was not signed by the prescribing medical practitioner. 5. A review of R3's medical record revealed a medication order dated in September 2023. The medication order indicated R3 was receiving assistance in the self-administration of medication for "Trazodone 100 mg tablet, take 1 tablet by oral route every bedtime". 6. A review of R3's medical record revealed a medication order dated in January 2024 for "Fluoxetine 10mg Liquid". However, the medication order was not signed by the prescribing medical practitioner. 7. A review of R3's medical record revealed a MAR dated January 2024. The MAR indicated R3 received assistance in the self-administration of the following: -Trazodone 100mg tab, take 1 tab by mouth at bedtime; and -Fluoxetine 10mg cap, take 1 cap by mouth daily. The MAR indicated assistance in the self-administration provided to R3 for Trazodone 100mg tab on January 1 and 17, 2024 was not available for review; and Fluoxetine 10 mg capsule on January 1, 2, 9, 10, 11, 20, 21, 23, 25-28, and 30-31, 2024 was not available for review. 8. In an interview, R3 stated "has no issues with medications", "takes meds when they call me over and I sign", and "I sign after I take them." 9. A review of R4's medical record revealed a MAR dated May 2023. The MAR indicated R4 received assistance in the self-administration of Guanfacine 2mg in May 1-31, 2024. 10. A review of R4's medical record revealed documentation titled "Monthly Assessment" dated May 1, 2024. The documentation stated R4 was "supposed to be taking guanfacine 2mg but has run out of the medication." 11. A review of R5's medical record revealed a progress note dated December 6, 2023. The progress note stated R5 "took a Vistaril and said it made [R5] feel worse. [R5] has refused to take any additional does." However, R5's MAR for December 2023 indicated assistance in the self-administration of Vistaril 500mg capsule was not provided to R5. 12. In an interview, E1 acknowledged the facility did not provide assistance in the self-administration of medication in compliance with an order, and did not document assistance in the self administration in the resident's medical record.

rule: D. An administrator shall ensure that: 1. A current drug reference guide is available for use by personnel members;

evidence: Based on observation and interview, the administrator failed to ensure a current drug reference guide was available for use by personnel members.

findings: 1. The Compliance Officer requested to review a current drug reference guide. However, a current drug reference guide was not available for review. 2. In an interview, E1 reported a current drug reference guide was not available for review in hard copy or an electronic format.

rule: D. An administrator shall ensure that: 2. A current toxicology reference guide is available for use by personnel members; and

evidence: Based on observation and interview, the administrator failed to ensure a current toxicology reference guide was available for use by personnel members.

findings: 1. The Compliance Officer requested to review a current toxicology reference guide. However, a current toxicology reference guide was not available for review. 2. In an interview, E1 reported the facility did not have a current toxicology reference guid in hard copy or an electronic format.

rule: B. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 2. The disaster plan required in subsection (B)(1) is reviewed at least once every 12 months;

evidence: Based on documentation review and interview, the administrator failed to ensure the disaster plan required in subsection (B)(1) was reviewed at least once every 12 months. The deficient practice posed a risk if employees implemented an outdated disaster plan.

findings: 1. A review of facility documentation revealed a disaster plan (review date not available). However, documentation of a disaster plan review at least once every 12 months was not available for review. 2. In an interview, E1 acknowledged the disaster plan was not reviewed at least once every 12 months.

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

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

findings: 1. A review of Department documentation revealed the perpetual license for BH7118 was effective December 22, 2021. 2. A review of facility documentation revealed a daily staffing schedule. The staffing schedule revealed the facility maintained four shifts: -First shift from 8:00 AM to 4:00 PM; -Second shift from 8:00 AM to 8:00 PM; -Third shift from 8:00 PM to 8:00 AM; and -Fourth shift from 10:00 PM to 8:00 AM. 3. A review of facility documentation revealed the facility's scope of services. The documentation indicated the facility maintained two shifts: -First shift from 8:00 AM to 8:00 PM; and -Second shift from 8:00 PM to 8:00 AM. 4. A review of facility documentation revealed documentation of disaster drills was not available for review. 5. In an interview, E1 confirmed the facility maintained four shifts. E1 acknowledged a disaster drill for employees was not conducted on each shift at least once every three months. This is a repeat citation from the compliance inspection conducted on February 13, 2023.

rule: B. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 5. An evacuation drill for employees and residents on the premises is conducted at least once every six months on each shift;

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

findings: 1. A review of Department documentation revealed the perpetual license for BH7118 was effective December 22, 2021. 2. A review of facility documentation revealed a daily staffing schedule. The staffing schedule revealed the facility maintained four shifts: -First shift from 8:00 AM to 4:00 PM; -Second shift from 8:00 AM to 8:00 PM; -Third shift from 8:00 PM to 8:00 AM; and -Fourth shift from 10:00 PM to 8:00 AM. 3. A review of facility documentation revealed the facility's scope of services. The documentation indicated the facility maintained two shifts: -First shift from 8:00 AM to 8:00 PM; and -Second shift from 8:00 PM to 8:00 AM. 4. A review of facility documentation revealed documentation of evacuation drills conducted on the following dates and shifts: -November 28, 2023 on the second shift; and -February 6, 2024 on the first shift. However, documentation of evacuation drills conducted at least once every six months on each shift was not available for review. 5. In an interview, E1 confirmed the facility maintained four shifts. E1 acknowledged an evacuation drill for residents and employees was not conducted at least once every six months on each shift. This is a repeat citation from the compliance inspection conducted on February 13, 2023.

rule: C. An administrator shall: 3. Maintain documentation of a current fire inspection.

evidence: Based on observation and interview, the administrator failed to ensure the facility maintained documentation of a current fire inspection.

findings: 1. The Compliance Officer observed a wall with facility postings. The Compliance Officer observed a posting of the fire inspection permit. However, the fire inspection permit expired October 8, 2022. 2. In an interview, E1 acknowledged documentation of a current fire inspection for the facility was not maintained.

rule: R9-10-113. Tuberculosis Screening A. If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that: 2. Include: c. Annually providing training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed by or providing volunteer services for the health care institution;

evidence: Based on documentation review and interview, the health care institution's chief administrative officer failed establish and document tuberculosis (TB) infection control activities to include annual training and education related to recognizing the signs and symptoms of TB to individuals employed by the health care institution. The deficient practice posed a potential TB exposure risk to residents.

findings: 1. A review of facility documentation revealed TB infection control activities including annual training and education related to recognizing the signs and symptoms of TB was not available for review. 3. In an interview, E1 acknowledged the facility did not establish and document TB infection control activities to include annual training and education.