facility_name: BOJ RESIDENTIAL HOMES

summary: Complaint - 3/16/2026

raw_content: The following deficiencies were found during the on-site investigation of complaint 00159903 conducted on March 16, 2026:

rule: A.R.S. § 36-411.A-H. Residential care institutions; nursing care institutions; home health agencies; fingerprinting requirements; exemptions; definitions A. Except as provided in subsection F of this section, as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work or contracted work. B. A health professional who has complied with the fingerprinting requirements of the health professional's regulatory board as a condition of licensure or certification pursuant to title 32 is not required to submit an additional set of fingerprints to the department of public safety pursuant to this section. C. Each residential care institution, nursing care institution and home health agency shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency. 2. Verify the current status of a person's fingerprint clearance card. 3. Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459. If a potential employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency may not hire the potential employee. 4. On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459. If an employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency shall take action to terminate the employment of that employee. 5. Beginning March 31, 2025, annually reverify that each employee is not on the adult protective services registry pursuant to section 46-459. D. An employee, an owner, a contracted person or a volunteer or a facility on behalf of the employee, the owner, the contracted person or the volunteer shall submit a completed application that is provided by the department of public safety within twenty days after the date the person begins work or volunteer service. E. Except as provided in subsection F of this section, a residential care institution, nursing care institution or home health agency shall not allow an employee to continue employment or a volunteer or contracted person to continue to provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services if the person has been denied a fingerprint clearance card pursuant to title 41, chapter 12, article 3.1, has been denied approval pursuant to this section before May 7, 2001 or has had a fingerprint clearance card suspended or revoked. F. An employee, volunteer or contractor of a residential care institution, nursing care institution or home health agency who is eligible pursuant to section 41-1758.07, subsection C to petition the board of fingerprinting for a good cause exception and who provides documentation of having applied for a good cause exception pursuant to section 41-619.55 but who has not yet received a decision is exempt from the fingerprinting requirements of this section if the person provides medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services to residents or patients while under the direct visual supervision of an owner or employee who has a valid fingerprint clearance card. G. If a person's employment record contains a six-month or longer time frame during which the person was not employed by any employer, a completed application with a new set of fingerprints shall be submitted to the department of public safety. H. For the purposes of this section: 1. "Direct supportive services": (a) Means services other than home health services that provide direct individual care and that are not provided in a common area of a health care institution, including: (i) Assistance with ambulating, bathing, toileting, grooming, eating and getting in and out of a bed or chair. (ii) Assistance with self-administration of medication. (iii) Janitorial, maintenance, housekeeping or other services provided in a resident's room. (iv) Transportation services, including van services. (b) Does not include services provided by persons contracted directly by a resident or the resident's family in a health care institution. 2. "Direct visual supervision" means continuous visual oversight of the supervised person that does not require the supervisor to be in a superior organizational role to the person being supervised. 3. "Home health services" has the same meaning prescribed in section 36-151.

evidence: Based on record review and interview, the residential care institution failed to verify each employee was not on the adult protective services registry pursuant to section 46-459, for two of two personnel records sampled. The deficient practice posed a risk to the safety of residents if E1 and E3 were a danger to a vulnerable population.

findings: A.R.S. § 36-411.C. Each residential care institution, nursing care institution and home health agency shall make documented, good faith efforts to: 4. On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459. If an employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency shall take action to terminate the employment of that employee. 1. A review of E1's and E3's personnel records revealed no documentation of an adult protective services registry check was available. 2. In an exit interview, E1 reviewed the findings and no additional documentation was provided for review. 3. In a telephonic exit interview, the findings were reviewed with E2. E2 reported a registry check was completed for both employees. However, the adult protective services registry checks for E1 and E3 were not provided for review.

rule: A.R.S. § 8-804.D. Central registry; notification; definition D. Licensees that do not contract with this state, that contract with the federal government, that receive only federal monies and that employ persons who provide direct services to children in a licensed behavioral health residential facility pursuant to title 36, chapter 4 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 child safety may charge a fee to licensees to conduct central registry background checks pursuant to this subsection. The department of health services shall verify whether the licensees, pursuant to title 36, chapter 4, have complied with the requirements of this subsection.

evidence: Based on record review and interview, the licensee failed to conduct a Department of Child Safety central registry background check, for two of two personnel records sampled. The deficient practice posed a risk if E1 and E3 were a danger to a vulnerable population.

findings: 1. A review of E1's and E3's personnel records revealed no documentation of a department of child safety central registry check was available. 2. In an exit interview, E1 reviewed the findings and provided the Compliance Officer with a "Direct Services Central Registry Clearance Form" for E1 and E3. However, the department of child safety registry check documentation for E1 and E3, indicating the results of the search, was not provided for review. 3. In a telephonic exit interview, the findings were reviewed with E2. E2 reported a registry check was completed for both employees. However, the department of child safety registry checks for E1 and E3 were not provided for review.

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

evidence: Based on documentation review, record review, and interview, the chief administrative officer failed to implement tuberculosis (TB) infection control activities, including providing annual training and education related to signs and symptoms of TB, for two of two personnel records sampled. The deficient practice posed a potential TB exposure risk to residents.

findings: R9-10-113.A.2.c. 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; 1. A review of facility documentation revealed a policy titled "Tuberculosis Screening Program," dated January 23, 2024. The policy stated, "... A. Education and training each employee, student, or volunteer must complete a 'New Hire Orientation' and receive continuous training as part of continued employment with the company. Continuous training shall be completed on the employee's anniversary date. The following information shall be documented and placed in the employee's file. The 2019 MMWR CDC/NTCA recommendations include annual education being provided to all healthcare personnel (HCP)..." 2. A review of E1's and E3's personnel records revealed no documentation of completed TB signs and symptoms training was available. 3. In an exit interview, E1 reviewed the findings and no additional documentation was provided for review. 4. In a telephonic exit interview, the findings were reviewed with E2 and no additional documentation or statements were provided for review.

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 in-service education as required by policies and procedures, for two of two personnel records sampled. The deficient practice posed a risk as the repeated violation shows a pattern of noncompliance to ensure the health and safety of residents.

findings: 1. A review of facility documentation revealed a policy titled "New Hire Orientation," dated October 24, 2024. The policy stated, "... 1.2 Content... Crisis prevention intervention training... 2.1 Timing: Ongoing training is required annually or as needed, based on updates in regulations or identified areas for improvement..." 2. A review of facility documentation revealed a policy titled "Physical Health and Safety," dated October 24, 2024. The policy stated, "... 11. Behavioral Intervention: Responses to sudden, intense, or out-of-control behavior will prioritize safety, de-escalation, and prevention of harm..." 3. A review of E1's personnel record revealed no documentation of completed crisis prevention intervention training was available for review. 4. A review of E3's personnel record revealed a crisis prevention intervention training valid from August 3, 2024, to August 3, 2025. However, no documentation of a current crisis prevention intervention training was available for review. 5. In an exit interview, E1 reviewed the findings and no additional documentation was provided for review. 6. In a telephonic exit interview, the findings were reviewed with E2 and no statements or additional documentation were provided for review. This is a repeated violation from the February 21, 2023 compliance inspection.

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 a treatment plan was developed for each resident to include the signature of the resident's representative, and date signed, or documentation of the refusal to sign, for two of two residents sampled. The deficient practice posed a risk if the resident or the resident's representative did not agree to the treatment plan, and the repeated violation shows a pattern of noncompliance to ensure the health and safety of residents.

findings: 1. A review of R1's medical record revealed a treatment plan dated in December 2025. However, the treatment plan did not include the signature of the resident's representative, date signed, or the refusal to sign. 2. A review of R1's medical record revealed a treatment plan dated in February 2026. However, the treatment plan did not include the signature of the resident's representative, date signed, or the refusal to sign. 3. A review of R1's medical record revealed a treatment plan dated in March 2026. However, the treatment plan did not include the signature of the resident's representative, date signed, or the refusal to sign. 4. A review of R2's medical record revealed a treatment plan dated in January 2026. However, the treatment plan did not include the signature of the resident's representative, date signed, or the refusal to sign. 5. In an exit interview, E1 reviewed the findings and no additional documentation was provided for review. 6. In a telephonic exit interview, the findings were reviewed with E2 and no additional statements or documentation were provided for review. This is a repeated violation from the October 23, 2025 complaint and compliance inspection.

rule: R9-10-708.A.4.f. Treatment Plan A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that: 4. Includes: f. The signature of the personnel member who developed the treatment plan and the date signed;

evidence: Based on record review and interview, the administrator failed to ensure a treatment plan was developed for each resident to include the signature of the personnel member who developed the treatment plan, for two of two residents sampled. The deficient practice posed a risk as the repeated violation shows a pattern of noncompliance to ensure the health and safety of residents.

findings: 1. A review of R1's medical record revealed a treatment plan dated in December 2025. However, the treatment plan did not include the signature of the personnel member who developed the treatment plan. 2. A review of R1's medical record revealed a treatment plan dated in February 2026. However, the treatment plan did not include the signature of the personnel member who developed the treatment plan. 3. A review of R1's medical record revealed a treatment plan dated in March 2026. However, the treatment plan did not include the signature of the personnel member who developed the treatment plan. 4. A review of R2's medical record revealed a treatment plan dated in January 2026. However, the treatment plan did not include the signature of the personnel member who developed the treatment plan. 5. In an exit interview, E1 reviewed the findings and no additional documentation was provided for review. 6. In a telephonic exit interview, the findings were reviewed with E2, and E2 reported the name of the individual who developed the treatment plan was typed in the treatment plan. This is a repeated violation from the October 23, 2025 complaint and compliance inspection.

rule: R9-10-718.C.3. Medication Services C. If a behavioral health residential facility provides assistance in the self-administration of medication, an administrator shall ensure that: 3. Policies and procedures for assistance in the self-administration of medication are reviewed and approved by a medical practitioner or registered nurse;

evidence: Based on documentation review and interview, the administrator failed to ensure policies and procedures for assistance in the self-administration of medication were reviewed and approved by a medical practitioner or registered nurse.

findings: R9-10-101.24. “Assistance in the self-administration of medication” means restricting a patient’s access to the patient’s medication and providing support to the patient while the patient takes the medication to ensure that the medication is taken as ordered. 1. A review of facility documentation revealed a policy and procedure titled "Resident Self-Administration [sic] and Medication Assistance [sic]" dated January 27, 2024. However, no evidence the policy and procedure was reviewed and approved by a medical practitioner or registered nurse was available. 2. In an exit interview, E1 reviewed the findings and reported the facility provided assistance in the self-administration of medication. 3. In a telephonic exit interview, the findings were reviewed with E2. E2 reported a medical practitioner created the policy and procedure and acknowledged there was no evidence the policy and procedure was reviewed and approved by a medical practitioner or registered nurse.


state: AZ

summary: Complaint - 2/12/2026

raw_content: The following deficiencies were found during the on-site  investigation of complaint 00158710 conducted on February 12, 2026:

inspection_type: Complaint

rule: R9-10-706.E.2. Personnel E. An administrator shall ensure that: 2. A personnel member completes orientation before providing behavioral health services or physical health services;

evidence: Based on record review and interview, the administrator failed to ensure a personnel member completed orientation before the personnel member provided behavioral health services, for one of one personnel members sampled. The deficient practice posed a risk if E3 was not oriented to the facility.

findings: 1. A review of R2's resident record revealed a "Resident Progress Note" signed by E3 which stated, -"Date of Service:..." -"Time In: 2pm Time Out: 9pm -"Staff/Clinician: E3" -"Presenting Status/Behavior:.. [R2] had a good day we went to the park. [R2] had fun and did a lot of running. [R2] came home and took a shower. [R2] ate [R2's] dinner and did a puzzle." 2. A review of E3's personnel record revealed a document titled "New Hire Orientation" and listed "Employee Name [E3]." However, the document was not completed. 3. In an exit interview, the findings were reviewed with E1, and no additional comments, statements, or documentation were provided regarding the findings.

rule: R9-10-706.G.3.e. Personnel G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes: 3. Documentation of: e. The individual's compliance with requirements in A.R.S. §§ 36-411, 36-411.01, and 36-425.03, as applicable;

evidence: Based on record review and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of the individual's compliance with requirements in Arizona Revised Statutes (A.R.S.) §§ 36-425.03, for one of one personnel records sampled. The deficient practice posed a risk if E3 was not a good fit to work in a children's behavioral health residential facility.

findings: A.R.S. § 36-425.03(E) Children's behavioral health program personnel shall certify on forms that are provided by the department and notarized that they are not awaiting trial on or have never been convicted of or admitted in open court or pursuant to a plea agreement to committing any of the offenses listed in section 41-1758.03, subsection B or C in this state or similar offenses in another state or jurisdiction. 1. A review of E3's personnel record revealed no notarized documentation that E3 was not awaiting trial, on or have been convicted of or admitted in open court or pursuant to a plea agreement, of 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. In an exit interview, the findings were reviewed with E1, and no additional comments, statements, or documentation were provided regarding the findings. This is a repeated deficiency from the on-site compliance inspection and complaint investigation conducted on February 21, 2023, November 25, 2024, and October 23, 2025.

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 that included documentation of the individual's compliance with the requirements in A.R.S. § 8-804, for one of one personnel records sampled. The deficient practice posed a risk to the health and safety of residents if E3 was unfit to work at a children's behavioral health residential facility.

findings: A.R.S. § 8-804.(J). "J. Before being employed in a position that provides direct services to children or vulnerable adults pursuant to subsection B, paragraphs 4, 5, 10 and 11 or subsections C, 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 placed on the central registry. 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 E3's personnel record revealed a form titled "Direct Service Central Registry Clearance Form." However, the document was not dated, and the "For Arizona DCS Central Registry Use Only" section was blank. Results from the DCS Central Registry check were not provided on-site. 2. In an exit interview, the findings were reviewed with E1, and no additional comments, statements, or documentation were provided regarding the findings. This is a repeated deficiency from the on-site compliance inspection and complaint investigation conducted on October 23, 2025, and the on-site plan of correction inspection conducted on December 2, 2025.


summary: Complaint - 1/27/2026

raw_content: The following deficiencies were found during the on-site  investigation of complaint 00157100 conducted on January 27, 2026.

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

evidence: Based on record review and interview, the administrator failed to ensure a personnel member's skills and knowledge were verified and documented before the personnel member provided behavioral health services, for one of three personnel members sampled. The deficient practice posed a risk if E3 was unable to meet a resident's needs.

findings: 1. A review of E3's personnel record revealed no documentation E3's skills and knowledge were verified before E3 provided behavioral health services. 2. In an interview, E1 reported E3’s skills and knowledge were verified, but was not able to provide documentation. 3. In a joint exit interview, the findings were reviewed with E1 and E4. No additional comments or documentation were provided.

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

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure sufficient personnel members were present on the behavioral health residential facility's premises with the qualifications, experience, skills, and knowledge necessary to ensure the health and safety of a resident. The deficient practice posed a health and safety risk if E3 was unable to respond appropriately to a resident’s needs.

findings: 1. In a review of the Gilbert Police Department report GO# GI 2026-15557, it stated “…Occurred On January 24, 2026 at 5:53 pm…Anna got in the way to try to separate the two girls from fighting but struggled…” 2. A review of facility documentation revealed a document titled “ BOJ Residential Homes Administrative Policies and Procedures”. The document includes “…This policy applies to all employees and contractors working as BHT’s…1. Behavioral Health Technician (BHT)…1.2 Qualifications Minimum of two years of experience in a behavioral health-related field…” 3. A review of facility documentation revealed a document titled “Jan 2026...BOJ Residential Homes – Staff Calendar” with no date numbers. The document listed E1 and E2 on the schedule for Saturdays in January 2026, from 2:00 pm. To 9:00 pm. E3 is not on the schedule. 4. A review of facility documentation revealed a document titled “BOJ Residential Homes Incident Report”. The report stated, “…Date of incident: Saturday, January 24, 2026 Time of Incident: Approximately 6:30 p.m…R1 escalated and struck R2 in the face…” 5. In a telephonic interview, E4 reported E3 was the only personnel member at the facility during the incident on January 24, 2026. 6. In an interview, E1 reported E3 was the only personnel member at the facility during the incident on January 24, 2026. E1 reported E1 and E2 were working but had left the facility for approximately 30 minutes when the incident occurred. 7. A review of E3’s personnel record revealed no documentation of qualifications, experience, skills, and knowledge applicable to job duties, and to ensure the health and safety of a resident. 8. In a joint exit interview, the findings were reviewed with E1 and E4. No additional comments or documentation were provided. This is a repeated violation from the complaint inspection conducted on January 6, 2026, and the compliance inspection conducted on August 23, 2024.

rule: R9-10-706.K.3.b. Personnel K. An administrator shall ensure that: 3. There is a daily staffing schedule that: b. Includes documentation of the employees who work each calendar day and the hours worked by each employee; and

evidence: Based on documentation review and interview, the administrator failed to ensure there was a daily staffing schedule to include documentation of the hours worked by each employee. The deficient practice posed a safety risk as there was no accurate record to verify sufficient, qualified personnel members and employees were present or available to meet the needs of the residents.

findings: 1. A review of facility documentation revealed a document titled “Jan 2026...BOJ Residential Homes – Staff Calendar” with no date numbers. The document listed E1 and E2 on the schedule for Saturdays in January 2026, from 2:00 pm. To 9:00 pm. E3 is not on the schedule. 2. In an interview, E1 reported the document titled “Jan 2026...BOJ Residential Homes – Staff Calendar” was the only schedule for the entire month of January. 3. In an interview, E1 reported E3 was the only personnel member present at the facility during the incident on January 24, 2026. E1 reported that E1 and E2 were working yet had left the facility for approximately 30 minutes when the incident occurred. 4. In a joint exit interview, the findings were reviewed with E1 and E4. No additional comments or documentation were provided.


summary: Complaint - 1/6/2026

raw_content: The following deficiencies were found during the on-site  investigation of complaint 00155259 conducted on January 6, 2026:

evidence: Based on documentation review and interview, the administrator failed to ensure sufficient personnel members were present on a behavioral health residential facility's premises with the qualifications, experience, skills, and knowledge necessary to ensure the health and safety of a resident. The deficient practice posed a risk as R2 did not receive continuous protective oversight, and the repeated violation shows a pattern of noncompliance to ensure the health and safety of residents.

findings: 1. A review of Department documentation revealed BH7153 was licensed to provide behavioral health services to individuals whose behavioral health issue limits the individuals' ability to function independently (individuals under 18 years of age). 2. A review of facility documentation revealed an incident report dated in December 2025. The report stated, “On the above date and time, client [R2] eloped from the BOJ Residential Homes property during routine daily chores. At the time of the incident, residents were completing assigned chores. [R2] was under close supervision due to a prior elopement history. [R2] was directed to take garbage to the outdoor garbage bin located in the self-contained, locked backyard. [E1 and E4] maintained direct visual supervision during this task. [R2] placed the garbage into the outdoor trash bin while staff observed. Immediately thereafter, [R2] unexpectedly jumped over the backyard wall, exiting the secured area without authorization. The backyard gate was locked at the time. [E4] immediately responded by entering the home to unlock the front door and initiated a search of the surrounding area. [R2] was not located. Additional staff and administrators were promptly notified, and a thorough search of the neighborhood and surrounding area was filed. A follow-up search of the client’s bedroom was conducted as part of elopement procedures. During the room search, staff discovered a handwritten letter authored by [R2]. In the letter, [R2] expressed remorse for leaving and stated that staff should not call the police, indicating that [R2] intended to return and that [R2] “just needed a break from BOJ.” 3. In a joint exit interview, the findings were discussed with E1 and E5 (telephonically), and no additional statements or documentation were provided regarding the findings. This is a repeated violation from the August 23, 2024 complaint inspection.

rule: R9-10-712.B.2. Medical Records B. If a behavioral health residential facility maintains residents' medical records electronically, an administrator shall ensure that: 2. The date and time of an entry in a resident's medical record is recorded by the computer's internal clock.

evidence: Based on record review and interview, the administrator failed to ensure the date and time of an entry in a resident's medical record was recorded by the computer's internal clock, for two of three medical records sampled. T

findings: 1. A review of R2's electronic medical record revealed documentation of a treatment plan dated August 2025. The documentation included E2’s and E5’s typed names and dates. However, the electronic document did not include the date and time of the treatment plan entry into R2’s medical record by the computer’s internal clock. 2. A review of R2's electronic medical record revealed documentation of a treatment plan dated December 2025 The documentation included E2’s and R2’s parent’s typed names and dates. However, the electronic document did not include the date and time of the treatment plan entry into R2’s medical record by the computer’s internal clock. 3. A review of R3's electronic medical record revealed documentation of a treatment plan dated December 2025. The documentation included E2’s typed name and date. However, the electronic document did not include the date and time of the treatment plan entry into R3’s medical record by the computer’s internal clock. 4. In an interview, E1 acknowledged with a head nod that the aforementioned documents did not include the required time and date stamps. 5. In a joint exit interview, the findings were reviewed with E1 and E5 (telephonically), and no additional statements or documentation were provided.

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

evidence: Based on documentation review and interview, the administrator failed to ensure, if a behavioral health residential facility was licensed to provide behavioral health services to individuals whose behavioral health issue limits the individuals' ability to function independently, a resident admitted to the behavioral health residential facility with limited ability to function independently received continuous protective oversight. The deficient practice posed a risk as R2 did not receive continuous protective oversight, and the repeated violation shows a pattern of noncompliance to ensure the health and safety of residents.

findings: 1. A review of Department documentation revealed BH7153 was licensed to provide behavioral health services to individuals whose behavioral health issue limits the individuals' ability to function independently (individuals under 18 years of age). 2. A review of facility documentation revealed an incident report dated in December 2025. The report stated, “On the above date and time, client [R2] eloped from the BOJ Residential Homes property during routine daily chores. At the time of the incident, residents were completing assigned chores. [R2] was under close supervision due to a prior elopement history. [R2] was directed to take garbage to the outdoor garbage bin located in the self-contained, locked backyard. [E1 and E4] maintained direct visual supervision during this task. [R2] placed the garbage into the outdoor trash bin while staff observed. Immediately thereafter, [R2] unexpectedly jumped over the backyard wall, exiting the secured area without authorization. The backyard gate was locked at the time. [E4] immediately responded by entering the home to unlock the front door and initiated a search of the surrounding area. [R2] was not located. Additional staff and administrators were promptly notified, and a thorough search of the neighborhood and surrounding area was filed. A follow-up search of the client’s bedroom was conducted as part of elopement procedures. During the room search, staff discovered a handwritten letter authored by [R2]. In the letter, [R2] expressed remorse for leaving and stated that staff should not call the police, indicating that [R2] intended to return and that [R2] “just needed a break from BOJ.” 3. A review of facility documentation revealed a daily staffing schedule for December 2025. The staffing schedule revealed two personnel members were scheduled to work on the date and time of R2’s 12:30 PM unauthorized absence. 4. In an interview, E1 reported E4 and R2 were taking the garbage out. E1 reported R2 jumped the fence and ran away. E4 tried to go after R2, but R2 continued to run away. E4 eventually lost sight of R2. 5. In a joint exit interview, the findings were discussed with E1 and E5 (telephonically), and no additional statements or documentation were provided regarding the findings. This is a repeated violation from the November 25, 2024 compliance and complaint inspection.


summary: Complaint;Compliance (Annual) - 10/23/2025

raw_content: The following deficiencies were found during the on-site compliance inspection and investigation of complaint 00148030 conducted on October 23, 2025:

inspection_type: Complaint;Compliance (Annual)

rule: A.R.S. § 36-420.01.A. 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 administrator failed to ensure staff received initial training and continued competency training in fall prevention and fall recovery, for three of eight personnel records sampled. The deficient practice posed a risk to the health and safety of residents if they were unable to be safely assisted during a fall.

findings: 1. A review of facility documentation revealed policies and procedures. The policies titled, "Fall Prevention and Recovery" stated, "As part of continued employment with BOJ Residential Homes must complete training in the new hire orientation and then annually on his or her anniversary date of the initial training." 2. A review of E2's and E4's personnel records revealed "Certification Of Training" forms for "Fall Prevention and Recovery Training." However, E2's and E4's "Fall Prevention and Recovery Training" was past due based on the training completion date listed on the certificates. 3. A review of E5's personnel record revealed no documentation of initial training in fall prevention and fall recovery training. 4. In a joint exit interview, the findings were reviewed with E1 and E2, and no additional comments or statements were provided regarding the findings. This is a repeated violation from the on-site compliance inspection and complaint investigation completed on January 10, 2024.

rule: R9-10-706.G.3.a. 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: a. The individual's qualifications, including skills and knowledge applicable to the individual's job duties;

evidence: Based on record review and interview, the administrator failed to ensure a personnel record was maintained for a personnel member to include documentation of the individual's qualifications, including skills and knowledge applicable to the individual's job duties, for one of eight personnel records sampled. The deficient practice posed a risk if E5 was not qualified to work at the behavioral health residential facility.

findings: 1. A review of E5's personnel record revealed no documentation of the individual's qualifications, including skills and knowledge applicable to the individual's job duties. 2. In a joint exit interview, the findings were reviewed with E1 and E2 and no additional comments or statements were provided regarding the findings.

evidence: Based on record review and interview, the administrator failed to ensure a personnel record was maintained for each personnel member that included documentation of the individual's compliance with requirements in 36-425.03, for one of eight personnel records sampled. The deficient practice posed a risk to the health and safety of residents as the personnel member had contact with a vulnerable population without a notarized affidavit or documented information or recommendations relevant to an individual's fitness for employment in a children's behavioral health residential facility.

findings: A.R.S. § 36-425.03. "A. Except as provided in subsections B, C and D of this section, children's behavioral health program personnel, including volunteers, shall submit the form prescribed in subsection E of this section to the employer and shall have a valid fingerprint clearance card issued pursuant to title 41, chapter 12, article 3.1 or, within seven working days after employment or beginning volunteer work, shall apply for a fingerprint clearance card." 1. A review of E5's personnel record revealed no documentation of requirements of requirements in 36-425.03 including a notarized affidavit, information or recommendations relevant to E5's fitness for employment in a children's behavioral health residential facility, and a fingerprint clearance card application within seven working days after employment. The record contained an application for a fingerprint clearance card dated September 29, 2025. E5's hire date was August 2025. 2. A review of facility documentation revealed a staffing schedule. E5 was scheduled to work Monday-Friday in October 2025. 3. In a joint exit interview, the findings were reviewed with E1 and E2, and no additional comments or statements were provided regarding the findings. 4. An off-site review of the Arizona Department of Public Safety website revealed the status of the application was "Not Valid" and dated "10/28/2025." This is a repeated deficiency from the on-site compliance inspection and complaint investigation conducted on February 21, 2023, and November 25, 2024

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

findings: 1. A review E5's and E7's personnel record did not reveal documentation of requirements in A.R.S. § 8-804. 2. In a joint exit interview, the findings were reviewed with E1 and E2 and no additional comments or statements were provided regarding the findings.

rule: R9-10-706.G.3.h. 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: h. Cardiopulmonary resuscitation training, if required for the individual according to R9-10-703(C)(1)(e);

evidence: Based on record review, documentation 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, for two of eight personnel records sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency, accident, or injury.

findings: 1. A review E5's personnel record revealed no documentation of CPR training. 2. A review of E7's personnel record revealed documentation of CPR training. However, the CPR training was completed as an online course which did not include a demonstration of the individual's ability to perform CPR. 3. A review of the "American Health Care Academy" website revealed courses were conducted online. The "American Health Care Academy" website stated the following: -"Leading Provider for Online CPR Certification" -"Our video-based lessons are designed to help you learn intuitively so you’re not only reading! Our CPR videos will help you gain a deeper understanding of CPR concepts so you can be ready in a real life emergency." -"We have designed the courses to fit your demanding/busy schedules. However, each course (s) is about 1-2 hours long. You don’t need to complete the enrolled course in a single sitting. Log out and back in anytime again." 4. In a joint exit interview, the findings were reviewed with E1 and E2 and no additional comments or statements were provided regarding the findings.

rule: R9-10-706.G.3.i. 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: i. First aid training, if required for the individual according to this Article or policies and procedures; and

evidence: Based on record review and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of first aid training, for one of eight records sampled. The deficient practice posed a risk if E5 was unable to meet a resident's needs during an accident.

findings: 1. A review E5's personnel record did not reveal documentation of first aid training. 2. In a joint exit interview, the findings were reviewed with E1 and E2 and no additional comments or statements were provided regarding the findings.

rule: R9-10-706.G.3.j. 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: j. Evidence of freedom from infectious tuberculosis, if required for the individual according to subsection (F).

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

findings: 1. A review E5's personnel record revealed no documentation of evidence of freedom from infectious tuberculosis. 2. A review of facility documentation revealed policies and procedures. The procedure for tuberculosis stated, "a. Staff must present documentation they have received a negative TB skin test within the last six months prior to starting work." 3. In a joint exit interview, the findings were reviewed with E1 and E2, and no additional comments or statements were provided regarding the findings.

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

findings: 1. A review of R2's medical record revealed a treatment plan. However, the treatment plan was not signed by the resident or the resident's representative. 2. In a joint exit interview, the findings were reviewed with E1 and E2 and no additional comments or statements were provided regarding the findings.

evidence: Based on record review and interview, the administrator failed to ensure that a treatment plan is developed and implemented for each resident that included the date signed, for one of two resident records sampled. The deficient practice posed a risk as the date the treatment plan was authenticated could not be determined.

findings: 1. A review of R2's medical record revealed a treatment plan. However, the treatment plan did not indicate the date signed. 2. In a joint exit interview, the findings were reviewed with E1 and E2, and no additional comments or statements were provided regarding the findings.

rule: R9-10-712.C.9. Medical Records C. An administrator shall ensure that a resident's medical record contains: 9. Orders;

evidence: Based on observation, record review, and interview, the administrator failed to ensure a resident's medical record contained orders for one of two resident records sampled. The deficient practice posed a health and safety risk as assistance in the self-administration of medication could not be verified against a medication order.

findings: 1. A review of R1's medications revealed a bottle of "Escitalopram 5 MG Tablet Take 1 tablet by mouth every day" The prescription label stated, "DATE FILLED: 9/29/25." 2. A review of R1's medical record revealed a medication administration record (MAR) for October 2025. The MAR revealed R1 was provided assistance in the self-administration of medication for "Escitalopram" on the following dates and times. -October 15, 2025, at 7:00 PM -October 22-23, 2025, at 7:00 AM However, no documentation for "Escitalopram" was available for review for September 2025." 3. A review of R1's medical record revealed there was no signed medication order for the "Escitalopram 5 MG Tablet." 4. In an interview, E1 reported the medication was taken by R1 and not documented. 5. In a joint exit interview, the findings were reviewed with E1 and E2 and no additional comments or statements were provided regarding the findings.

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

evidence: Based on record review and interview, the administrator failed to ensure that counseling was provided according to the number of hours identified in the resident's treatment plan, for two of two resident records sampled. The deficient practice posed a risk if a resident did not receive treatment to cure, improve, or palliate the resident’s behavioral health issue at the health care institution.

findings: 1. A review of R1's and R2's medical records revealed treatment plans. However, the treatment plans did not contain the number of hours for counseling. 2. In a joint exit interview, the findings were reviewed with E1 and E2, and no additional comments or statements were provided regarding the findings.

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

evidence: Based on observation, record review, and interview, the administrator failed to ensure assistance in the self-administration of medication provided to a resident was in compliance with an order, for one of two 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. 1. A review of R1's medications revealed a bottle of "Escitalopram 5 MG Tablet Take 1 tablet by mouth every day." The prescription label stated, "DATE FILLED: 9/29/25." 2. A review of R1's medical record revealed a medication administration record (MAR) for October 2025. The MAR revealed R1 was provided assistance in the self-administration of medication for "Escitalopram" on the following dates and times. -October 15, 2025, at 7:00 PM -October 22-23, 2025, at 7:00 AM However, no documentation for "Escitalopram" was available for review for September 2025. 3. A review of R1's medical record revealed there was no signed medication order for the "Escitalopram 5 MG Tablet." 4. In an interview, E1 reported the medication was taken by R1 and not documented. 5. In a joint exit interview, the findings were reviewed with E1 and E2 and no additional comments or statements were provided regarding the findings.

rule: R9-10-718.C.6.b. Medication Services C. If a behavioral health residential facility provides assistance in the self-administration of medication, an administrator shall ensure that: 6. Assistance in the self-administration of medication provided to a resident: b. Is documented in the resident's medical record.

evidence: Based on observation, record review, and interview, the administrator failed to ensure assistance in the self-administration of medication provided to a resident was documented in the resident's medical record, for one of two records sampled. The deficient practice posed a health and safety risk if a resident were to experience a change in condition due to improper assistance in the self-administration of medication.

findings: 1. A review of R1's medications revealed a bottle of "Escitalopram 5 MG Tablet Take 1 tablet by mouth every day." The prescription label stated, "DATE FILLED: 9/29/25." 2. A review of R1's medical record revealed a medication administration record (MAR) for October 2025. The MAR revealed R1 was provided assistance in the self-administration of medication for "Escitalopram" on the following dates and times. -October 15, 2025, at 7:00 PM -October 22-23, 2025, at 7:00 AM However, no documentation for "Escitalopram" was available for review for September 2025. 3. A review of R1's medical record revealed there was no signed medication order for the "Escitalopram 5 MG Tablet." 4. In an interview, E1 reported the medication was taken by R1 and not documented. 5. In a joint exit interview, the findings were reviewed with E1 and E2, and no additional comments or statements were provided regarding the findings.

rule: R9-10-720.B.2. Emergency and Safety Standards B. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 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 was reviewed at least once every 12 months. The deficient practice posed a risk if personnel members were unable to ensure the health and safety of residents during a disaster, emergency or unexpected event.

findings: 1. A review of facility documentation revealed a "Disaster Plan Review Form" dated 2021. 2. In a joint exit interview, the findings were reviewed with E1 and E2 and no additional comments or statements were provided regarding the findings.

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

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

findings: 1. A review of facility documentation revealed a binder of disaster drill templates. However, no documentation of completed disaster drills were available for review. 2. In a joint exit interview, the findings were reviewed with E1 and E2 and no additional comments or statements were provided regarding the findings. This is a repeated violation from the on-site compliance inspection completed on February 21, 2023, and compliance inspections and complaint investigations completed on January 10, 2024, and November 25, 2024.

rule: R9-10-720.B.5. Emergency and Safety Standards B. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 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 employees and residents on the premises was conducted at least once every six months on each shift. The deficient practice posed a risk if the employees were not able to implement the disaster plan in the case of the need to evacuate in an emergency.

findings: 1. A review of facility documentation revealed a binder of evacuation drill templates. However, no documentation of completed evacuation drills was available for review. 2. In a joint exit interview, the findings were reviewed with E1 and E2, and no additional comments or statements were provided regarding the findings. This is a repeated violation from the on-site compliance inspection completed on February 21, 2023, and on-site compliance and complaint inspections completed on January 10, 2024, and November 25, 2024.


summary: Modification - 10/23/2025

raw_content: No deficiencies were found during the on-site inspection to increase the occupancy from 4 to 5, conducted on October 24, 2025.

inspection_type: Modification


summary: Complaint - 6/2/2025

raw_content: An on-site investigation of complaints AZ00132181 and AZ00132182 was conducted on June 2, 2025, and the following deficiencies were cited:

rule: R9-10-707.A.1.b. Admission; Assessment A. An administrator shall ensure that: 1. A resident is admitted based upon: b. The resident's behavioral health issue and treatment needs are within the behavioral health residential facility's scope of services;

evidence: Based on record review, documentation review, and interview, the administrator failed to ensure a resident was admitted based upon the resident's behavioral health issue and treatment needs within the behavioral health residential facility's scope of services.

findings: 1. A review of R1's medical record revealed a document titled "Prior Authorization Request for Children and Adolescents BHF, BHRF, and HCTC" (dated in April 2025). The document stated, "[R1] is continually a follower of others and frequently engages in DTS [danger to self] behaviors..." 2. A review of R1's medical record revealed a behavioral health assessment (dated November 2024). The assessment indicated R1 had a "past history of cutting behaviors." 3. A review of facility documentation revealed a policy and procedure (effective date February 2, 2023) titled "Program Description." The policy stated, “…Services Provided: BOJ Residential Homes Offer: Counseling, Assistance in the Self-administration of Medication, ILS [Independent Living Skills], ADL [Activities of Daily Living], Support Groups, Substance Relapse and Prevention, Using Coping Skills Effectively, Anger Management, Conflict Resolution, Assertive Training, Exploring New Challenges…” However, the description did not include if services would be provided to an individual with a history of DTS. 4. In an interview, E5 acknowledged a resident who was a danger to themselves was more suited for a behavioral health inpatient facility. E5 recalled during a Child and Family Team Meeting, the issue was discussed, and it was decided R1's admission to the behavioral health residential facility was appropriate because R1 had not recently engaged in self-harming behaviors. However, no documentation was provided for review that the behavioral health residential facility's scope of services included if services would be provided to an individual with a history of DTS. 5. In an exit interview, the findings were discussed with E5, and no additional statements or documentation were provided.

rule: R9-10-708.A.4.d. Treatment Plan A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that: 4. Includes: d. The date when the resident's treatment plan will be reviewed;

evidence: Based on record review and interview, the administrator failed to ensure a treatment plan was developed and implemented for each resident to include the date when the resident's treatment plan would be reviewed, for one of two residents sampled.

findings: 1. A review of R1's medical record revealed a treatment plan (dated April 2025). However, the plan did not include the date when R1's treatment plan would be reviewed. 2. In an interview, E5 acknowledged R1's treatment plan did not include the date when R1's treatment plan would be reviewed. 3. In an exit interview, the findings were discussed with E5, and no additional documentation or statements were provided.

rule: R9-10-716.A.7.a. Behavioral Health Services A. An administrator shall ensure that: 7. A resident does not: a. Use or have access to any materials, furnishings, or equipment or participate in any activity or treatment that may present a threat to the resident's health or safety based on the resident's documented diagnosis, treatment needs, developmental levels, social skills, verbal skills, or personal history; or

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a resident did not use or have access to any materials that may present a threat to the resident's health or safety based on the resident's documented diagnosis or personal history. The deficient practice posed a risk as R1 had access to scissors while admitted into a behavioral health residential facility, in contradiction with their documented diagnosis and personal history of self-harming behavior.

findings: 1. A review of facility documentation revealed an incident report regarding R1 (dated May 2025). The report stated, "Staff went over and asked if [R1] had decided to go to bed for the night. [R1] did not answer and went to the restroom. The staff could tell the client was not responding and needed space. [R1] was in the restroom for about 10 minutes. The staff checked on [R1] and [R1] said [R1] was fine. [R1] was prompted to open the door if done. [R1] did, and went to [R1's] room very quietly. [R1] did not come out of her room. The staff realized the quietness, followed up and saw [R1] with small sized scissors in [R1's] hand with minor lines on [R1's] upper wrist. The staff collected the scissors from [R1], escorted [R1] to the med room area and started first aid. [R1] insisted [R1] wanted to do it [for R1] because it's a cut [R1] can handle and the staff should allow [R1] to clean [for R1]. [R1] refused to let staff attend to [R1]. [R1] expressed that “I can take care of myself”. From what the staff could see, the wound looked more like a scratch than a cut. The staff charted the urge to self-harm, checked on [R1] every 10 minutes for about an hour as [R1] fell asleep in [R1's] bed. [R1] had a quiet night." 2. A review of R1's medical record revealed a behavioral health assessment (dated November 2024). The assessment indicated R1's diagnosis was, "Unspecified trauma- and stressor-related disorder." 3. A review of R1's medical record revealed a document titled "Prior Authorization Request for Children and Adolescents BHF, BHRF, and HCTC" (dated in April 2025). The document stated, "[R1] is continually a follower of others and frequently engages in DTS [danger to self] behaviors..." 4. A review of R1's medical record revealed a treatment plan (dated in April 2025). The treatment plan stated, "[R1] will decrease impulsive behaviors and the need to self-harm within the next 60 days." 5. A review of R1's medical record revealed a note signed by E8 (dated May 2025). The note stated, '[E8] discussed with [R1] being able to identify [R1's] emotions prior to self-harming situations and working on those emotions so that [R1] does not use self-harm as a coping skill." 6. A review of R1's medical record revealed a document titled "Summary of Session" (dated May 2025. The document indicated between 10:30 p.m.-11:30 p.m., "[R1] was holding a scissors wanting to harm [R1] in the room so [E7] collected it." 7. In an interview, E5 reported to be unaware of how R1 obtained the scissors in the aforementioned incident. E5 acknowledged the administrator failed to ensure R1 did not use or have access to the scissors that presented a threat to R1's health and safety based on R1's documented trauma diagnosis and personal history of self-harming behaviors. 8. In an exit interview, the findings were discussed with E5, but no additional documents or statements were provided.


summary: Complaint - 8/23/2024

raw_content: An on-site investigation of complaint AZ00214970 was conducted on August 23, 2024 and the following deficiencies were cited:

rule: C. An administrator shall ensure that: 2. Policies and procedures for behavioral health services and physical health services are established, documented, and implemented to protect the health and safety of a resident that: a. Cover resident screening, admission, assessment, treatment plan, transport, transfer, discharge planning, and discharge;

evidence: Based on documentation review, record review, and interview, the administrator failed to implement policies and procedures for behavioral health services to protect the health and safety of a resident to cover transport and transfer. The deficient practice posed a health and safety risk to the residents that the established policies and procedures were not implemented.

findings: 1. In a documentation review, a policy titled "Responding to Immediate and unscheduled BH and Physical Services" last reviewed on February 2, 2023, revealed "...PROCEDURE...In the event of a behavioral or physical emergency the following protocol shall be utilized...The RN shall write a detailed note regarding what was going on with the resident if the resident was transported to a higher level of care. Documentation shall include the date and time and where the resident was transported to...An incident report shall be completed...A note shall be made with a detailed description of what the problem is, in the resident's medical record...." 2. In a documentation review, the Compliance Officer requested the incident report regarding R2's injury from August 16, 2024. The facility was unable to provide the report. 3. In a record review of R1's and R2's medical records, it revealed no notes were created regarding where the residents were transported to, the dates or times and by which staff. 4. In a joint interview, E1 and E3 acknowledged the licensed facility did not implement their policies and procedures to cover the transfer and transportation of R1 and R2 to a higher level of care.

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 risk as the facility did not immediately report to the department of child safety (DCS) when a resident's family member informed the facility of suspected abuse as DCS was unable to assess if there was an immediate health and safety concern for the resident and other residents residing in the behavioral health residential facility.

findings: A.R.S. \'a7 36-3620(A)(5) 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...For the purposes of this subsection, "person" means: Any other person who has responsibility for the care or treatment of the minor. R9-10-101.110 states "Immediate" means without delay. 1. In a documentation review, a policy titled "Abuse, Neglect, and Exploitation of Residents" last reviewed on February 2, 2023, revealed "...Any employee...who is aware of any abuse or neglect of a resident must report whether actual, suspected or alleged MUST report it immediately to his/her supervisor to being an immediate investigation. Abuse is considered: Inflicting physical pain on a resident...Any unreasonable confinement...Employees should complete an incident report...All cases of abuse are to be reported to AHCCCS, ADHS, Associated mental health agency and BOJ Residential Homes administrator...BOJ Residential Homes will conduct a thorough investigation and report its findings...BOJ Residential Homes will follow the recommendations of ADHS and associated mental health agencies...." 2. In an interview, E1 reported the guardian of R1 called in a complaint about potential employee abuse of R1 on August 18, 2024. 3. In a documentation review, the compliance officer requested the incident and investigation report from August 18, 2024, no report was provided . 4. In an interview, E1 acknowledged the administrator failed to report the suspected abuse, neglect, or exploitation of a resident under 18 years of age. E1 reported he would document the results of the investigation immediately, stay late to ensure its completion and bring in additional staff for the evening shift so the investigation could be documented correctly.

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

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

findings: 1. In a documentation review, a policy titled "Incident Reporting" last reviewed on February 2, 2023, revealed "...BOJ Residential Homes has established and implemented policies and procedures for documenting and reporting incidents surrounding health and safety issues regarding the residents in the home...Reporting requirements...Documentation required on an incident report...Any witnesses...Staff names and titles witnessing...." 2. In a documentation review an incident report revealed "...Date of Incident [07/31/2024]...6:15pm...Reported by: (E1, E4)...(R1) took off (their) seatbelt and tried to get at a (R2)...safety cautions were in place for all clients...After 10 minutes (R1) calmed down and was given a chance to make a good decision, which (they) moved back to (their) seat...It was a 20 minute transport back to the home...." 3. In a documentation review an incident report revealed "...Date of Incident [08/16/2024]...6:40pm...Reported by: (E1, E2)...(R1) came from nowhere and hit (R2's) the peer's head with...sandals two times...Staff attended to injured peer...The injured peer got a little bit dizzy and the staff had to hold (them) for some time...staff was monitoring any sign of unconsciousness, when (R1) ran from 1:1 staff, very violent and rushed to the injured peer again....(R1) ran to another peer, who was trying to stay away and punched and kicked the client who was then isolated in their room...(R1) ran again towards a towards a peer who was going for a cup of water....Please note that the peer (R2) that was hit by the client was taken to urgent care due to injury to the head. The team wanted to rule out concussion as a result of the peer complaining about dizziness and a headache...If the member is to return, it is recommended that the member be placed on 1 to 1 until (they) become more stable...BHP recommendations: It is recommended that the member be placed on 1 to 1 if (they) are to return. It has become unsafe otherwise for others as well as the client for (them) not to have the additional coverage...." 4. In a record review of R1's medical records a treatment plan from July 3, 2024, revealed "...Specific Services and Frequency...1:1 staff resident monitoring...." 5. In a record review of R2's medical records a treatment plan from February 5, 2024, revealed "...Specific Services and Frequency...1:1 staff resident monitoring...." 6. In a documentation review of facility reports, no evidence could be produced that R1 and R2 had specific employees assigned to their 1:1 care on July 31, 2024, or August 16, 2024, by the exit survey. 7. In a joint interview, E1 and E3 acknowledged the aforementioned documentation could not be produced revealing that sufficient staff were on site for July 31, 2024 and August 16, 2024.

rule: K. An administrator shall ensure that: 3. There is a daily staffing schedule that: a. Indicates the date, scheduled work hours, and name of each employee assigned to work, including on-call personnel members; b. Includes documentation of the employees who work each calendar day and the hours worked by each employee; and c. Is maintained for at least 12 months after the last date on the documentation;

evidence: Based on documentation review and interview, the administrator failed to ensure there was a daily staffing schedule to indicate the name of each employee assigned to work, including on-call personnel members; and included documentation of the employees who work each calendar day and the hours worked by each employee. The deficient practice posed a safety risk if there was no record to ensure tasks were covered.

findings: 1. The Compliance Officer requested a daily staffing schedule for July 2024 and August of 2024, at 11:45 AM. One undated weekly "Staff Schedule" was produced. 2. A review of the facility document "Staff Schedule" revealed no dates and no documentation of the employees that worked each calendar day in July and August of 2024. 3. In an interview, E1 acknowledged the daily staffing schedule was not maintained and did not include dates and documentation of the employees who worked each calendar day and the hours worked by each employee.

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: d. When a resident has a significant change in condition or experiences an event that affects treatment.

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure that a treatment plan was developed and implemented for each resident that was reviewed and updated on an ongoing basis when a resident had a significant change in condition or experiences an event that affects treatment. This deficient practice posed a safety risk that the residents treatment is not being updated to meet their changing needs.

findings: 1. In a documentation review, a policy titled "Treatment Plan" last reviewed on February 2, 2023, revealed "...The treatment plan will address on-going changes with the resident...." 2. In a documentation review, an incident report from August 16, 2024 revealed "...6:40pm...(R1) came from nowhere and hit (R2's) the peer's head with...sandals two times...when (R1) ran from 1:1 staff, very violent and rushed to the injured peer again....(R1) ran to another peer, who was trying to stay away and punched and kicked the client who was then isolated in their room...(R1) ran again towards a towards a peer who was going for a cup of water...If the member is to return, it is recommended that the member be placed on 1 to 1 until (they) become more stable...BHP recommendations: It is recommended that the member be placed on 1 to 1 if (they) are to return. It has become unsafe otherwise for others as well as the client for (them) not to have the additional coverage...." 3. In a record review of R1's medical record, progress notes revealed that R1 was at another inpatient facility at a higher level of care after this incident on August 16, 2024 until their return to the licensed behavioral health residential facility on August 19, 2024. 4. In a record review of R1's medical record, one treatment plan dated July 3, 2024, was revealed. A review of R1's medical record revealed no additional treatment plans were available for review following a a significant change or after R1 experienced an event that affected R1's treatment. 5. In a interview, E1 reported R1 experienced a significant change in condition or experienced that affected R1's and no treatment plan was updated.

rule: C. An administrator shall ensure that a resident is discharged from a behavioral health residential facility when the resident's treatment needs are not consistent with the services that the behavioral health residential facility is authorized and able to provide.

evidence: Based on observation, documentation review and interview, the administrator failed to ensure a resident was discharged from the behavioral health residential facility when the resident's treatment needs were not consistent with the services the behavioral health residential facility was authorized and able to provide. The deficient practice posed a safety risk to the other residents within the facility.

findings: 1. In an enviromental tour of the facility, the Compliance Officer observed a hole in the wall near the kitchen. 2. In a documentation review of an incident report dated July 27, 2024, it stated, "...when suddenly, (R1) got mad and started to yell and scream. While the other client had the remote, (R1) then suddenly hit the other client in the chest. The staff immediately stopped (R1) from hitting the other client at which time he stated to curse at staff using the "F" word, while kicking and punching the staff. It was then that staff took (R1) to (their) room to calm (them) down, however (R1) continued to kick and punch staff...." 3. In a documentation review of an incident report dated July 31, 2024, it stated, "...(R1) took off (their) seatbelt and tried to get at (R2), who was sitting in the seat behind (them)...At this time (R1) was asked to sit down repeatedly and put (their) seatbelt on but (R1) did not....(R1) tried getting to the client (R2) again, throwing a fist, kicked the staff and punched the staff other side, who tried to prevent (R1) from reaching the other client (R2)...." 4. In a documentation review of an incident report dated August 3, 2024, it was stated, "...the member (R1) displaying aggressive and enviromental (sic) behaviors as evident by screaming, yelling and attacking...It was also during the incident the member started to lash out at other members that are in the home by throwing...pillows and trying to attack them. This went on for about 35 to 40 minutes before the team was able to calm the member...." 5. In a record review of R1's medical record, a progress note dated August 10, 2024 stated, "...Time: 8:30AM to 9:00AM Client is observe (sic) to be picking on (their) peers...." 6. In a documentation review of an incident report dated [August 16, 2024] it was revealed "...6:40pm...(R1) came from nowhere and hit (R2's) the peer's head with...sandals two times...Staff attended to injured peer...The injured peer got a little bit dizzy and the staff had to hold (them) for some time...staff was monitoring any sign of unconsciousness, when (R1) ran from 1:1 staff, very violent and rushed to the injured peer again....(R1) ran to another peer, who was trying to stay away and punched and kicked the client who was then isolated in their room...(R1) ran again towards a towards a peer who was going for a cup of water....Please note that the peer (R2) that was hit by the client was taken to urgent care due to injury to the head. The team wanted to rule out concussion as a result of the peer complaining about dizziness and a headache...If the member is to return, it is recommended that the member be placed on 1 to 1 until (they) become more stable...BHP recommendations: It is recommended that the member be placed on 1 to 1 if (they) are to return. It has become unsafe otherwise for others as well as the client for (them) not to have the additional coverage...." 7. In a record review of R1's medical record, a progress note revealed R1 to be at a higher level of care after this incident on August 16, 2024, from 10:30 PM until their return to the licensed facility on August 19, 2024. 8. In an interview, E1 confirmed R1 has caused property damage including kicking holes in the walls at the facility. E1 acknowledged R1's behaviors have increased dramatically from their admission in [July of 2024] to include property damage, physical attacks on other residents and staff of the licensed facility, and the targeting of R2 that routinely interrupts treatment and resident activities. 9. In an interview, E1 reported R1 has become too violent and unpredictable with other residents and staff of the licensed facility and needed a higher level of care.

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

evidence: Based on documentation review and interview, the administrator failed to ensure a resident was treated with dignity, respect and consideration. The deficient practice posed a health and safety risk to the resident, as facility policy was not followed.

findings: 1. A review of the facility policy titled "Resident Rights" last reviewed February 2, 2023, revealed "...Purpose: To ensure residents' rights are not violated...PROCEDURE: All staff...shall be trained in Resident Rights to make sure the rights are not being violated...To receive assistance from a family member...in...protecting, or exercising the resident's rights...." 2. In an interview, E1 acknowledged they received a complaint telephonically on August 18, 2024, from a family member of R1, about potential abuse of R1 by E2. 3. In an interview, E1 acknowledged the licensed facility did not ensure it residents were treated with consideration after receiving assistance from a family member in protecting the residents' rights.


summary: Complaint;Compliance (Annual) - 1/10/2024

raw_content: The following deficiencies were found during the on-site compliance inspection and investigation of complaint AZ00200419 conducted on December 10, 2023:

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

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

findings: 1. A review of facility documentation revealed a policy and procedure titled "Fall Prevention and Fall Recovery" dated February 2022. The policy and procedure stated " ... All personnel must complete an initial training in the "New Hire Orientation," the training is to be updated on the anniversary date of the initial training... All training certificates shall be maintained in the employees employment record..." 2. A review of E1's (hired as the administrator), E2's (hired as the behavioral health technician), E3's (hired as the program coordinator), E4's (hired as the registered nurse) and E6's (hired as the behavioral health professional) personnel records revealed initial training and continued competency training in fall prevention and fall recovery were not available for review. 3. In an interview, E1 reported E1, E2, E3, E4 and E6 had completed training. However, documentation of the training was not available for review. 4. In an interview, E1 acknowledged initial training and continued competency training in fall prevention and fall recovery for E1, E2, E3, E4 and E6 was not available for review. This is a repeat deficiency from the compliance inspection conducted on February 21, 2023.

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

evidence: Based on documentation review and interview, the administrator failed to ensure documentation of current contracted services was maintained, for the behavioral health professional (BHP). The deficient practice posed a risk as the administrator did not have a contract for a behavioral health professional.

findings: 1. The Compliance Officer requested to review E5's, the BHP's, personnel record at 10:10 AM. 2. A review of facility documentation revealed a contract dated for August 23, 2023. However the contract was not signed and authenticated by E5. 3. In a interview, E1 acknowledged the administrator failed to ensure documentation of current contracted services was maintained for the BHP.

rule: G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes: 1. The individual's name, date of birth, and contact telephone number; 2. The individual's starting date of employment or volunteer service and, if applicable, the ending date; and 3. Documentation of: a. The individual's qualifications, including skills and knowledge applicable to the individual's job duties; b. The individual's education and experience applicable to the individual's job duties; c. The individual's completed orientation and in-service education as required by policies and procedures; d. The individual's license or certification, if the individual is required to be licensed or certified in this Article or policies and procedures; e. The individual's compliance with the requirements in A.R.S. §§ 36-411, 36-411.01, and 36-425.03, as applicable; f. The individual ' s compliance with the requirements in A.R.S. § 8-804, if applicable; g. If the individual is a behavioral health technician, clinical oversight required in R9-10-115; 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 j. Evidence of freedom from infectious tuberculosis, if required for the individual according to subsection (F).

evidence: Based on record review and interview, the administrator failed to ensure a personnel record was maintained for each personnel member, employee, volunteer, or student, for one of six employees or volunteers sampled. The deficient practice posed a risk as required information could not be verified for E5.

findings: 1. The Compliance Officer requested to review a personnel record for E5, the BHP, however, no personnel record for was provided for review. 2. In an interview, E1 acknowledged a personnel record for E5 was not provided for review.

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

evidence: Based on documentation review, observation, record review, and interview, the administrator failed to ensure at least one personnel member was present at the behavioral health residential facility during hours of operation who had first aid and cardiopulmonary resuscitation (CPR) training specific to the populations served. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency or an accident.

findings: 1. A review of facility documentation revealed a policy and procedure titled "CPR and First aid Training Guidelines" (dated in February 2022). The policy stated "All employees must be trained in CPR and First Aid as part of their continued employment with BOJ Residential Homes... A copy of the employees CPR/First Aid card will be filed in their employee folders...Staff re-certification and renewals are due 30 days before the expiration dates on the CPR/First Aid cards.." 2. The Compliance Officer observed E1 on the premises and working alone when the Compliance Officer arrived at 9:30 AM. 3. A review of facility documentation revealed a document labeled "Boj employee availability (not dated). The document revealed E1 worked the shift labeled as "Day." 4. A review of E1's personnel record revealed documentation of CPR and first aid training from American Health Care Academy, specific to adult, child and infant, issued on September 8, 2021 with an expiration date of September 2023. However, no current CPR and first aid training was available to review. 5. In an interview, E1 acknowledged the administrator failed to ensure at least one personnel member with first aid and CPR training specific to adolescents was present at the behavioral health facility during hours of operation.

evidence: Based on documentation review and interview, the administrator failed to ensure there was a daily staffing schedule which indicated the date, scheduled work hours, and name of each employee assigned to work, including on-call personnel members, included documentation of the employees who worked each calendar day and the hours worked by each employee, and was maintained for at least 12 months after the last date on the documentation. 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 document labeled "BOJ Employee availability" not dated. However, no current staffing schedule was available for review. 2. In an interview, E1 reported staff used the employee availability as the schedule and staff worked the same shift every month. E1 acknowledged the administrator failed to ensure there was a daily staffing schedule which indicated the date, scheduled work hours, and name of each employee assigned to work, including on-call personnel members, included documentation of the employees who worked each calendar day and the hours worked by each employee, and was maintained for at least 12 months after the last date on the documentation.

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;

findings: 1. A review of facility documentation revealed a document labeled BOJ availability (not dated). The document revealed the facility had two shifts, day and night. However, did not specify the times of each shift. 2. The Compliance Officer requested to review disaster drills for the last 12 months. However, disaster drills were not provided for review. 3. In an interview, E1 acknowledged a disaster drill was not conducted on each shift at least once every three months and documented. This is a repeat deficiency from the compliance inspection conducted on February 21, 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 employees and residents on the premises 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 facility documentation revealed a document labeled BOJ availability (not dated). The document revealed the facility had two shifts, day and night. However, did not specify the times of each shift. 2. The Compliance Officer requested to review evacuation drills for the last 12 months. However, evacuation drills were not provided for review. 3. In an interview, E1 acknowledged an evacuation drill was not conducted on each shift at least once every six months and documented. This is a repeat deficiency from the compliance inspection conducted on February 21, 2023.


facility_name: LIFE IS A CIRCLE LLC

summary: Complaint - 12/30/2025

raw_content: The following deficiencies were found during the on-site  investigation of complaint 00153530 conducted on December 30, 2025:

rule: R9-10-703.G.2. Administration 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 within two working days of a resident injury requiring emergency medical intervention, as required by R9-10-703.G.2. The deficient practice posed a safety concern as timely notification to the Department is necessary to ensure appropriate oversight, monitoring, and response following serious resident injuries.

findings: 1. In a documentation review, an incident report submitted to the Arizona Health Care Cost Containment System(AHCCCS) titled "INCIDENT, ACCIDENT OR DEATH REPORT" revealed R1 fell from a height while at a playground, reported pain, and was transported to urgent care for evaluation. 2. In a documentation review, medical records indicated that an X-ray identified a distal tibia fracture, and R1 was subsequently transported to Banner Desert Medical Center, where R1 received a temporary brace and was prescribed medication. 3. In a documentation review, records did not indicate that a written notification of the incident was submitted to the Department. 4. In an interview, E2 reported the only understanding of the reporting was to report the incident to AHCCCS, as E2 believed AHCCCS would then forward the information to the Department of Health. 5. In an exit interview with E2, the findings were reviewed. No additional comments or documentation were provided.