summary: Complaint - 10/16/2025

raw_content: The following deficiency was found during the on-site investigation of complaint 00147793 conducted on October 16, 2025:

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, record review, and interview, the administrator failed to ensure a resident admitted to the behavioral health residential facility with limited ability to function independently received continuous protective oversight. The deficient practice posed a risk to the health and safety of residents if residents did not receive continuous protective oversight.

findings: 1. A review of facility documentation revealed a policy titled, "Behavioral and Physical Health Services." The policy stated, "... A. Continuous protective oversight and behavioral health services as indicated in the resident's treatment plan, which is based on the resident's needs, is to be provided to a resident admitted to the behavioral health residential facility with limited ability to functions independently..." 2. A review of R1's medical record revealed a treatment plan dated September 15, 2025. The plan stated, "... [R1] demonstrates an ongoing obsessive preoccupation with pornography, which continues to be a clinical concern from home and at [R1's] previous school. In addition, there was a prior incident at [R1's] former school where [R1] entered the girls' restroom; while no misconduct was reported, the behavior is concerning and warrants continued monitoring... Presenting Struggles... AWOL risk and flight behaviors..." 3. A review of R1's medical record revealed an incident report dated October 15, 2025. The report stated, "... Date of Incident: 10/15/2025; Day of Week: Wednesday; Time of Incident: 6:30 AM... Name of Staff Involved: [E6], [E5]; Type of Incident: AWOL; Police Involved: Yes - Requires notification of both executive and clinical directors; Severe AWOL: No; General Description of Incident: At approximately 6:30 AM, staff conducted the last set of rounds and observed [R1] using the restroom. At approximately 7:00 AM, staff called [R1's] name to administer medication but received no response. Staff checked the bathroom and [R1's] room and found no signs of [R1]. A search of the rest of the house was conducted, but [R1] was still not located. Staff then searched the outside property and observed that [R1's] bicycle was missing. The administrator was immediately contacted and began searching the surrounding area by vehicle, but there were no signs of [R1]. The BHP was notified, and the Pinal County Sheriff's Office was contacted. Deputy [O1] arrived on-site and conducted a report. Mother, the treatment team, and DCS were also notified. Staff spoke with [O2] from DCS. Staff does want to note that [R1] was informed during [R1's] therapy session yesterday that [R1] would be transferring to another group home today and was scheduled to be picked up at approximately 10:00 AM. [R1] showed no signs of distress, agitation, or concern when this information was shared... Further Action Required: Continue active search for [R1] until [R1] is safely located. Monitor all exits and property access points to prevent further absconding. Maintain ongoing communication with DCS, the treatment team, and law enforcement regarding updates. Staff to complete a review of current safety protocols and implement additional preventive measures as needed. Document any new developments in the incident log immediately. BHP, treatment team, Police, and DCS were all contacted." 4. In an interview, E1 reported staff will review the safety protocols and implement additional preventive measures as needed.


state: AZ

facility_name: LIFE IS A CIRCLE LLC

summary: Complaint;Compliance (Annual) - 6/5/2025

raw_content: The following deficiencies were found during the on-site investigation of complaint 00132558 and compliance inspection conducted on June 5, 2025:

inspection_type: Complaint;Compliance (Annual)

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, occupation health provider, as defined in A.A.C. R9-6-801, or local health agency, as defined in A.A.C. R9-6-101; c. Annually providing training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed by or providing volunteer services for the health care institution; d. Annually assessing the health care institution's risk of exposure to infectious tuberculosis; e. Reporting, as specified in A.A.C. R9-6-202, an individual who is suspected of exposure to infectious tuberculosis; and f. If an exposure to infectious tuberculosis occurs in the health care institution, coordinating and sharing information with the local health agency, as defined in A.A.C. R9-6-101, for identifying, locating, and investigating contacts, as defined in A.A.C. R9-6-101.

evidence: Based on record review and interview, the administrator failed to annually provide training and education related to recognizing the signs and symptoms of tuberculosis (TB). The deficient practice posed a TB exposure risk to residents.

findings: R9-10-113.B.1.c.(i-ii) B. A health care institution's chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specified in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: c. If the individual had a positive Mantoux skin test or other tuberculosis screening test according to subsection (B)(1)(a) and does not have history of tuberculosis or documentation of latent tuberculosis infection, as defined in A.A.C. R9-6-1201, a written statement: i. ii. That the individual is free from infectious tuberculosis, signed by a medical practitioner or local health agency, as defined in A.A.C. R9-6-101; and Dated within 12 months before the date the individual begins providing services at or on behalf of the health care institution or is admitted to the health care institution. 2. A review of E3's personnel record (hired June 2022) revealed documentation of TB signs and symptoms training was not available for review. 3. A review of R2's medical record revealed a negative PPD skin test. However, documentation of assessing risks of prior exposure to infectious TB and determining if R2 had signs or symptoms of TB was not available for review. 4. In an exit interview, E1 reviewed the findings, and no additional documentation was 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. The deficient practice posed a risk to the health and safety of residents.

findings: 1. A review of facility documentation revealed a policy titled, "Orientation and In-Service Training." The policy stated, "... CPI training will be provided upon hire and at least 12 months thereafter..." 2. A review of E5's (hired March 2025) personnel record revealed no documentation of crisis prevention intervention (CPI) training was available for review. 3. In an exit interview, E1 reviewed the findings, and no additional documentation was provided for review. This is a repeat deficiency from the compliance and complaint investigation conducted on March 6, 2023, the compliance inspection conducted on May 2, 2024, and the complaint investigation conducted on May 15, 2024.

rule: R9-10-706.K.3.a. Personnel K. An administrator shall ensure that: 3. There is a daily staffing schedule that: a. Indicates the date, scheduled work hours, and name of each employee assigned to work, including on-call personnel members;

evidence: Based on documentation review, observation, and interview, the administrator failed to ensure there was a daily staffing schedule that indicated the date, scheduled work hours, and name of each employee assigned to work, including on-call personnel members.

findings: 1. A review of facility documentation revealed a staffing schedule dated June 2025. The schedule stated, "... [E6] off..." However, E6 was working in the facility and there was no change noted in the "shift change" column of the staffing schedule. 2. The Compliance Officer observed E6 playing and drawing with the residents. 3. In an exit interview, E1 reviewed the findings and reported that there was a scheduling error. This is a repeat deficiency from the compliance and complaint investigation conducted on March 6, 2023, and the complaint investigation conducted on October 23, 2024.

rule: R9-10-707.A.10.b. Admission; Assessment A. An administrator shall ensure that: 10. If a behavioral health assessment that complies with the requirements in this Section is received from a behavioral health provider other than the behavioral health residential facility or if the behavioral health residential facility has a medical record for the resident that contains a behavioral health assessment that was completed within 12 months before the date of the resident's current admission: b. The review and update of the resident's assessment information is documented in the resident's medical record within 48 hours after the review is completed;

evidence: Based on record review and interview, the administrator failed to ensure a behavioral health assessment received from a behavioral health provider other than the behavioral health residential facility that was completed within 12 months before the date of the resident's current admission was reviewed, updated, and documented in the resident's medical record within 48 hours after the review was completed.

findings: 1. A review of R1's medical record revealed a behavioral health assessment from a behavioral health provider other than BH7205. However, there was no documentation reflecting the assessment was reviewed and updated within 48 hours. 2. In a telephonic interview, E2 reported the assessment was reviewed at admission, but a note reflecting the review and update was not documented. 3. In an exit interview, E1 reviewed the findings, and no additional documentation was provided for review.

rule: R9-10-712.C.15. Medical Records C. An administrator shall ensure that a resident's medical record contains: 15. Documentation of behavioral health services and physical health services provided to the resident;

evidence: Based on record review and interview, the administrator failed to ensure a resident's medical record contained documentation of behavioral health services provided to the resident. The deficient practice posed a risk to the health and safety of residents.

findings: 1. A review of R2's medical record revealed a treatment plan dated in 2025. The plan stated, "... Group counseling 5 to 7 days per week at Life is a Circle (LIAC); Additional services, 1:1 counseling with Grossman and Grossman 1-4xs a month; Behavioral coaching using CBT/REBT... Participate in therapy once a week: 1-4xs monthly... Meet with therapist weekly: identify and document specific psychosis symptoms including frequency and impact on daily life..." 2. A review of R2's medical record revealed that no documentation of 1:1 counseling was available for review. 3. In an exit interview, E1 reviewed the findings and reported the facility has reached out multiple times to "Grossman and Grossman" for individual counseling documentation but has not received any documentation.


summary: Complaint - 4/2/2025

raw_content:
This revised Statement of Deficiencies supersedes the Statement of Deficiencies sent to the licensee.

An on-site investigation of complaint 00124814 was conducted on April 2, 2025, and no deficiencies were cited.

inspection_type: Complaint


summary: Complaint - 10/23/2024

raw_content: An on-site investigation of complaint AZ00217785 was conducted on October 23, 2024 and the following deficiencies were cited :

rule: C. An administrator shall ensure that: 3. Policies and procedures are reviewed at least once every three years and updated as needed;

evidence: Based on documentation review and interview, the administrator failed to ensure policies and procedures were reviewed at least once every three years and updated as needed. The deficient practice posed a risk as the Department was unable to determine substantial compliance.

findings: 1. A review of facility documentation revealed a policy and procedure titled "Unauthorized Absence (AWOL)." However, the policy and procedure had a review date of June 2020. 2. The Compliance Officer requested to review documentation of when the administrator last reviewed the aforementioned policy and procedure as well as all other policies and procedures. However, no evidence of the revised documents could be provided. 3. In a joint interview, E1 and E2 acknowledged the aforementioned AWOL policy and procedure reported a review date of June 2020 and no documentation on when the policies and procedures were last reviewed was provided for review. This is a repeat citation from May 2, 2024.

rule: K. An administrator shall: 8. Maintain a written log of unauthorized absences for at least 12 months after the date of a resident's absence that includes the: a. Name of a resident absent without authorization, b. Name of the individual to whom the report required in subsection (K)(7) was submitted, and c. Date of the report; and

evidence: Based on documentation review and interview, the administrator failed to maintain a written log of unauthorized absences (AWOL) which included the name of the individual to whom the report required in subsection (K)(7) was submitted and the date of the report. The deficient practice posed a risk as the Department was unable to determine substantial compliance.

findings: R9-10-703 (K)(7): K. An administrator shall 7. If a resident ' s absence is unauthorized as determined according to the criteria in subsection conspire(K)(5), within an hour after determining that the resident ' s absence is unauthorized, notify: a. For a resident who is under 18 years of age, the resident ' s parent or legal guardian; and b. For a resident who is under a court ' s jurisdiction, the appropriate court: 1. A review of facility documentation revealed a written log of unauthorized absences titled "Life is a Circle Youth & Family Servives [SIC] Clients AWOL Log Sheet," which was filed in a black binder. However, the written log of unauthorized absences did not include the name of the individual to whom the report is required in subsection (K)(7) and the date of the report. 2. A review of the aforementioned unauthorized absence log revealed R1 had an unauthorized absence on October 22nd. However, documentation of the name of the individual to whom the report required in subsection (K)(7) was submitted and the date of the report were not documented for review. 3. In a joint interview, E2 reported all AWOL's were documented on the log and a report with the required information was filed in the aforementioned binder. E1 and E2 acknowledged the binder did not contain R1's report with the required information for R1's October 22nd AWOL. E2 reported E2 completed the report and contacted R1's guardian immediately. However, E1 and E2 acknowledged no documentation was available for review and the facility AWOL log was not in compliance.

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

evidence: Based on record review and interview, the administrator failed to ensure a personnel record was maintained for each personnel member which included documentation of the individual's compliance with the requirements in A.R.S. \'a7 8-804, for one of four personnel records sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance.

findings: A.R.S. \'a7 8-804(K) states "Before being employed in a position that provides direct services to children or vulnerable adults pursuant to subsection B, paragraphs 4, 5 and 10 and 11 or subsections C and D and E of this section, employees shall certify, under penalty of perjury, on forms that are provided by the department whether an allegation of abuse or neglect was made against them and was substantiated. The forms are confidential. If this certification does not indicate a current investigation or a substantiated report of abuse or neglect, the employee may provide direct services pending the findings of the central registry check." 1. A review of E3's (hired July 2024) personnel record revealed E3 was a behavioral health technician. However, E3's documentation in compliance with A.R.S. \'a7 8-804 was not on a form that was provided by the department. E3's documentation in compliance with A.R.S. \'a7 8-804 was on a form provided by the Department of Economic Security (DES). 2. In a joint interview, E1 and E2 acknowledged E3's documentation in compliance with A.R.S. \'a7 8-804 was required to be on a form provided by the department. E1 and E2 acknowledged E3's documentation was on a form provided by the Department of Economic Security (DES) and was not in compliance.

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 which indicated the date, scheduled work hours, and name of each employee assigned to work and included documentation of the employees who worked each calendar day and the hours worked by each employee. The deficient practice posed a health and safety risk as the Department was unable to determine substantial compliance.

findings: 1. In a document review, the facility documentation revealed a daily staffing schedule for October 2024. The daily staffing schedule did not indicate the date, scheduled working hours, and name of each employee assigned to work nor did it include the employees who worked each calendar day and the hours worked by each employee. 2. In a joint interview, E1 and E2 acknowledged the daily staffing schedule did not indicate the date, scheduled working hours, and name of each employee assigned to work nor did it include documentation of the employees who worked each calendar day and the hours worked by each employee. This is a repeat citation from March 6, 2023.

rule: B. An administrator shall ensure that: 8. A resident bedroom complies with the following: c. Contains a door that opens into a hallway, common area, or outdoors;

evidence: Based on observation and interview the administrator failed to ensure a resident bedroom contained a door that opened into a hallway, common area, or outdoors. The deficient practice posed a risk to residents as two bedrooms did not contain a door for privacy.

findings: 1. During an environmental tour of the facility, the Compliance Officer observed two resident bedrooms which had a sheet in the doorway opening. However, a door that opened into a hallway, common area, or outdoors was not available in either room. 2. In a joint interview, E1 and E2 reported they were under the impression since the residents were children, they were not allowed to have a door. E1 and E2 acknowledged all resident bedrooms were required to have a door which opened into a hallway, common area, or outdoors, unless their treatment plan indicated a specific reason as to why a door posed a risk to the resident. This is a repeat citation from May 2, 2024.

rule: B. An administrator shall ensure that: 8. A resident bedroom complies with the following: e. Has window or door covers that provide resident privacy;

evidence: Based on observation and interview, the administrator failed to ensure a resident's bedroom had window or door covers that provided resident privacy. The deficient practice posed a health risk as R4 did not have privacy.

findings: 1. The Compliance Officer's walked to the facility front door and observed a large wood plank leaning against the facility over a window. 2. During an environmental tour of the facility, the Compliance Officer viewed R4's bedroom and observed an open window with no glass. The window was covered by the aforementioned large wood plank. 3. In an interview, R4 reported R4's window broke and personnel members placed the large wood plank in front of the window from the outside to help block the wind from waking up the residents. 4. In a joint interview, E1 and E2 acknowledged the window in R4's bedroom was broken and did not prove resident privacy. E1 and E2 could not provide an exact date as to when the window broke. E1 and E2 did not provide documentation to show when the window would be fixed.


summary: Complaint - 10/2/2024

raw_content: An on-site investigation of complaint AZ00216840 was conducted on October 2, 2024 and no deficiency was cited.


summary: Complaint - 5/15/2024

raw_content: An on-site investigation of complaint AZ00210273 was conducted on May 15, 2024 and the following deficiencies were cited :

rule: A.R.S. § 36-407. Prohibited acts; required acts A. A person shall not establish, conduct or maintain in this state a health care institution or any class or subclass of health care institution unless that person holds a current and valid license issued by the department specifying the class or subclass of health care institution the person is establishing, conducting or maintaining. The license is valid only for the establishment, operation and maintenance of the class or subclass of health care institution, the type of services and, except for emergency admissions as prescribed by the director by rule, the licensed capacity specified by the license.

evidence: Based on documentation review, observation, and interview, the administrator failed to maintain in this state a health care institution with the approved occupancy and operations of the subclass of health care institution for which the Department issued a valid license. The deficient practice posed a risk to the health and safety of residents as the current occupancy and operations of the health care institution were outside the scope of the licensed behavioral health residential facility subclass.

findings: 1. A review of facility documentation revealed on February 11, 2022 the facility was licensed for a total capacity of seven residents. 2. A review of facility documentation revealed a certificate of occupancy from the Pinal County with the description, " Proposed Use: Behavioral Health Group Home 7 Occupant Ages 5-18 Capable of Self Preservation... Occupant Load: 7..." 3. A review of facility documentation revealed an initial application submitted to the Department of a floor plan with four labeled bedrooms, with a legend that stated "Bedroom three, one resident" and indicated bedroom three as a resident bedroom. 4. The Compliance Officer observed a locked bedroom door in the facility. 5. In an interview, E1 reported E2 was the only person who had keys to the bedroom. E1 reported the bedroom was E2's. 6. The Compliance Officer observed E2 open the locked door. The Compliance Officer observed a bed, dresser, and clothing. 7. In an interview, E1 acknowledged the health care institution failed to comply with A.R.S. \'a7 36-407(A).

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

evidence: Based on documentation review, record review, and interview, the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery including initial training and continued competency training in fall prevention and fall recovery. 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 policies and procedures manual titled, " Life is a Circle Youth and Families Services LLC." However, a program regarding fall prevention and fall recovery was not available for review. 2. A review of E3's personnel record revealed documentation of initial training and continued competency in fall prevention and fall recovery was not available for review. 3. In an interview, E1 acknowledged the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery. This is a repeat deficiency from the complaint and compliance inspection conducted on March 6, 2023.

evidence: Based on documentation review and interview, the administrator failed to maintain a written log of unauthorized absences. The deficient practice posed a risk if the facility did not maintain the required documentation to evaluate and take action related to the unauthorized absences of residents.

findings: 1. A review of facility documentation revealed a policy and procedure titled, " Unauthorized Absence (AWOL)." The policy stated, "... POLICY: A. A resident is considered on an unauthorized absence when: The involuntary resident or resident with a guardian/legal representative is not observed on the premise for more than 2 hours. In the event of an unauthorized absence status staff are to contact: Administrator on duty; Local enforcement and/or 911; Case manager/guardian; In the event for a resident who is under a court's jurisdiction, the appropriate court (A.R.S. Title 36, Chapter 5, Articles 1, 2, 3) is notified with a written report within an hour; B. Maintains a written log of unauthorized absences after the date of a resident's absence: 1. The log contains the name of the resident and the name to which the report was submitted; 2. Unauthorized logs are kept in administration for two years." 2. A review of facility documentation revealed an incident report dated May 12, 2024. The report stated, " Date of Report: 05-14-2024; Date of Incident: 05-14-2024; Resident Name: [R1]; Location of Incident: Neighborhood; Time: 10:15 PM; Reporting Staff: [E3]; Title: BHT; Incident Description: On the above date and approximate time, after both staff on site had already gotten all the clients in bed and assisted with medication administration. [R1] was sighted by staff during the hourly checks to be in bed. Then at the approximate time of 10:15 pm during lights out period, [R1] woke up and requested to go to the bathroom. [R1] went back to [R1's] room, then a few minutes later, sneaked out the house. The Police were contacted, and found [R1] at 10:26 pm walking down the street... Police Department returned [R1] home, reporting that when [R1] was interrogated, told them that [R1] cannot remember anything. [R1] stated that [R1] does not remember where [R1] lives, any of the staff, who [R1] was and all the likes. When back home, [R1] appeared dazed and confused. Officer also reported [R1] knocked on a neighbor's door. [R1] claims [R1] ran out because [R1] saw something [R1] was not supposed to see, and voices were telling [R1] to leave. As a result, the staff took [R1] to the... emergency room for the night, for purposes of diversion and reevaluation. At the... ER, [R1] was triaged and feedback given by the doctor that examined [R1] was to keep [R1] at the ER for a few more days till they could readjust [R1's] medications and also find [R1] a level one placement to address [R1's] auditory and visual hallucinations; Recommendations: [R1] needs to be evaluated further for any medical condition; Supplemental Report: Pinal County Sheriff Department Deputy to be reevaluated for [R1's] safety risk to the community." 3. A review of facility documentation revealed a written log of unauthorized absences (AWOL) was not available for review. 4. In an interview, E1 reported E1 did not have a written log of unauthorized absences.

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

evidence: Based on documentation review and interview, the administrator failed to evaluate and take action related to unauthorized absences under the quality management program in R9-10-704. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided, and posed a risk if the facility was unaware of the general or specific whereabouts of a resident.

findings: 1. A review of facility documentation revealed a policy and procedure titled, " Unauthorized Absence (AWOL)." The policy stated, "... POLICY: A. A resident is considered on an unauthorized absence when: The involuntary resident or resident with a guardian/legal representative is not observed on the premise for more than 2 hours. In the event of an unauthorized absence status staff are to contact: Administrator on duty; Local enforcement and/or 911; Case manager/guardian; In the event for a resident who is under a court's jurisdiction, the appropriate court (A.R.S. Title 36, Chapter 5, Articles 1,2,3) is notified with a written report within an hour; B. Maintains a written log of unauthorized absences after the date of a resident's absence: 1. The log contains the name of the resident and the name to which the report was submitted; 2. Unauthorized logs are kept in administration for two years." 2. A review of facility documentation revealed a policy and procedure titled, "Quality Management Plan and Procedure." The policy stated, "... III. Procedure: 1. The administrator ensures that all incidents identified, documented, and reviewed and policies are evaluated to improve on safety and well-being of residents: A. All incidents that must be reported are: i. all deaths; ii. all self-injuries requiring immediate medical interventions by a medical service provider; iii. all accidents requiring immediate medical interventions by a medical service provider; iv. all unauthorized substances; v. all related incidents and death; 2. Data is collected from the facility incident reports by the administrator; 3. The administrator reviews the incident reports for trends every thirty days; 4. The administrator identifies and implements a correction action upon identification of a concern about the safety or health issue; 5. Quality management reports are reviewed by the administrator monthly; 6. All incidents are reported to the administrator with 24 hours; 7. Reports are kept by the administrator for one year." 3. A review of facility documentation revealed a written log of unauthorized absences (AWOL) was not available for review. 4. A review of facility documentation revealed an evaluation of the unauthorized absences (AWOL) and documentation of action taken was not available for review. 5. In an interview, E1 reported E1 did not have a written log of unauthorized absences. 6. In an interview, E1 reported E1 did not evaluate and take action related to the unauthorized absence yet.

rule: An administrator shall ensure that: 1. A plan is established, documented, and implemented for an ongoing quality management program that, at a minimum, includes: a. A method to identify, document, and evaluate incidents;

evidence: Based on documentation review and interview, the administrator failed to ensure a quality management plan was implemented to include a method to identify, document, and evaluate incidents. The deficient practice posed a risk if the administrator did not take immediate action to prevent further unauthorized absences from occurring in the future.

findings: 1. A review of facility documentation revealed a policy and procedure titled, " Quality Management Plan and Procedure." The policy stated, "... III. Procedure: 1. The administrator ensures that all incidents identified, documented, and reviewed and policies are evaluated to improve on safety and well-being of residents: A. All incidents that must be reported are: i. all deaths; ii. all self-injuries requiring immediate medical interventions by a medical service provider; iii. all accidents requiring immediate medical interventions by a medical service provider; iv. all unauthorized substances; v. all related incidents and death; 2. Data is collected from the facility incident reports by the administrator; 3. The administrator reviews the incident reports for trends every thirty days; 4. The administrator identifies and implements a correction action upon identification of a concern about the safety or health issue; 5. Quality management reports are reviewed by the administrator monthly; 6. All incidents are reported to the administrator with 24 hours; 7. Reports are kept by the administrator for one year." 2. A review of facility documentation revealed an incident report dated May 12, 2024. The report stated, " Date of Report: 05-14-2024; Date of Incident: 05-14-2024; Resident Name: [R1]; Location of Incident: Neighborhood; Time: 10:15 PM; Reporting Staff: [E3]; Title: BHT; Incident Description: On the above date and approximate time, after both staff on site had already gotten all the clients in bed and assisted with medication administration. [R1] was sighted by staff during the hourly checks to be in bed. Then at the approximate time of 10:15 pm during lights out period, [R1] woke up and requested to go to the bathroom. [R1] went back to [R1's] room, then a few minutes later, sneaked out the house. The Police were contacted, and found [R1] at 10:26 pm walking down the street... Police Department returned [R1] home, reporting that when [R1] was interrogated, told them that [R1] cannot remember anything. [R1] stated that [R1] does not remember where [R1] lives, any of the staff, who [R1] was and all the likes. When back home, [R1] appeared dazed and confused. Officer also reported [R1] knocked on a neighbor's door. [R1] claims [R1] ran out because [R1] saw something [R1] was not supposed to see, and voices were telling [R1] to leave. As a result, the staff took [R1] to the... emergency room for the night, for purposes of diversion and reevaluation. At the... ER, [R1] was triaged and feedback given by the doctor that examined [R1] was to keep [R1] at the ER for a few more days till they could readjust [R1's] medications and also find [R1] a level one placement to address [R1's] auditory and visual hallucinations; Recommendations: [R1] needs to be evaluated further for any medical condition; Supplemental Report: Pinal County Sheriff Department Deputy to be reevaluated for [R1's] safety risk to the community." 3. A review of facility documentation revealed a plan to identify, document, and evaluate incidents was not implemented. 4. In an interview, E1 reported there was a staff meeting on May 15, 2024, to address the unauthorized absence which occurred on May 12, 2024. However, no documentation was available for review.

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

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure documentation of an individuals completed orientation was maintained in a personnel record, for one of eight personnel records sampled. The deficient practice posed a risk as employees were not orientated to the services to be provided to meet the needs of the residents.

findings: 1. A review of facility documentation revealed a policy and procedure titled, " Personnel Files." The policy stated, "... B. Content of Personnel File... 4. Documentation of: a. qualifications, skills, and knowldge applicable to the job duties; b. education and experience applicable to the job duties; competed orientation and in-service education per policies and procedures..." 2. A review of E3's personnel record revealed documentation of the individuals completed orientation was not available for review. 3. In an interview, E1 acknowledged documentation was not maintained in the personnel record. This is a repeat deficiency from the complaint and compliance inspection conducted on March 6, 2023.

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

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure at least one personnel member who was present at the behavioral health residential facility had first-aid and cardiopulmonary resuscitation (CPR) training to include a demonstration. The deficient practice posed a risk if E3 was unable to meet a resident's needs during an emergency or an accident. 1. A review of facility documentation revealed a staffing schedule titled, "Life is a Circle LLC Staff Schedule (May 12th-May 18th 2024)." The schedule stated," [E1] 9AM-9PM (on-call, med-aide & charge staff); [E2] 9PM-9AM/ 9PM-9AM (on-call, med-aide & charge staff); [E3] 9AM-9PM (med aide); [E4] 9AM-9PM (on-call, med-aide); [E5] 9AM-9PM (on-call, charge staff)..." 2. A review of E3's personnel record revealed documentation of First Aid and CPR for adult, children, and infants from "National Health & Safety Association" issued December 2, 2022 and valid until December 2, 2024. 3. A review of the "National Health & Safety Association" website revealed courses were conducted online. The "National Health & Safety Association" website stated "Online CPR certification made easy." 4. In an interview, E1 reported a second staff member is always on site. However, the staffing schedule did not reflect a second personnel member on shift from 9AM-9PM.

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

evidence: Based on record review, documentation review, and interview, the administrator failed to ensure behavioral health services as indicated in the resident's treatment plan and continuous protective oversight was provided. The deficient practice posed a risk as a behavioral health service listed in the treatment plan and continuous protective oversight was not provided on the premises.

findings: 1. A review of R1's medical record revealed a treatment plan dated April 11, 2024. The plan stated, "... 6. Participate in identified 1:1 and/or group counseling to address emotional challenges...; 2-4x weekly... 8. Participate in family therapy, utilizing coping skill materials...; Weekly..." 2. A review of R1's medical record revealed group therapy notes for the following dates: May 10, 2024; May 9, 2024; May 8, 2024; May 7, 2024; May 6, 2024; May 3, 2024; May 1, 2024; April 29, 2024; April 26, 2024; April 25, 2024; April 23, 2024; April 22, 2024; April 21, 2024; April 20, 2024... However, documentation of family therapy was not available for review. 3. A review of facility documentation revealed an incident report dated May 12, 2024. The report stated, " Date of Report: 05-14-2024; Date of Incident: 05-14-2024; Resident Name: [R1]; Location of Incident: Neighborhood; Time: 10:15 PM; Reporting Staff: [E3]; Title: BHT; Incident Description: On the above date and approximate time, after both staff on site had already gotten all the clients in bed and assisted with medication administration. [R1] was sighted by staff during the hourly checks to be in bed. Then at the approximate time of 10:15 pm during lights out period, [R1] woke up and requested to go to the bathroom. [R1] went back to [R1's] room, then a few minutes later, sneaked out the house. The Police were contacted, and found [R1] at 10:26 pm walking down the street... Police Department returned [R1] home, reporting that when [R1] was interrogated, told them that [R1] cannot remember anything. [R1] stated that [R1] does not remember where [R1] lives, any of the staff, who [R1] was and all the likes. When back home, [R1] appeared dazed and confused. Officer also reported [R1] knocked on a neighbor's door. [R1] claims [R1] ran out because [R1] saw something [R1] was not supposed to see, and voices were telling [R1] to leave. As a result, the staff took [R1] to the... emergency room for the night, for purposes of diversion and reevaluation. At the... ER, [R1] was triaged and feedback given by the doctor that examined [R1] was to keep [R1] at the ER for a few more days till they could readjust [R1's] medications and also find [R1] a level one placement to address [R1's] auditory and visual hallucinations; Recommendations: [R1] needs to be evaluated further for any medical condition; Supplemental Report: Pinal County Sheriff Department Deputy to be reevaluated for [R1's] safety risk to the community." 4. In an interview, E1 reported family therapy was provided online via telehealth but did not have documentation because E1 needed to request it. 5. In an interview, E1 acknowledged continuous protective oversight was not provided.

rule: C. If a behavioral health residential facility provides assistance in the self-administration of medication, an administrator shall ensure that: 4. Training for a personnel member, other than a medical practitioner or registered nurse, in assistance in the self-administration of medication: a. Is provided by a medical practitioner or registered nurse or an individual trained by a medical practitioner or registered nurse; and b. Includes: i. A demonstration of the personnel member's skills and knowledge necessary to provide assistance in the self-administration of medication, ii. Identification of medication errors and medical emergencies related to medication that require emergency medical intervention, and iii. The process for notifying the appropriate entities when an emergency medical intervention is needed;

evidence: Based on record review and interview, the administrator failed to ensure training of the assistance in the self-administration of medication was provided to a personnel member and documented. The deficient practice posed a risk if a resident experienced a change in condition due to improper assistance in the self-administration of medication.

findings: 1. A review of E3's personnel records revealed no documentation of assistance in the self-administration of medication training had been provided by a medical practioner or registered nurse or an individual trained by a medical practitioner or registered nurse. 2. In an interview, E1 acknowledged the administrator failed to ensure assistance in the self-administration training was provided to personnel members and documented in the personnel record. This is a repeat deficiency from the complaint and compliance inspection conducted on March 6, 2023.


summary: Compliance (Annual) - 5/2/2024

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on May 2, 2024:

inspection_type: Compliance (Annual)

rule: 36-425.03. Children's behavioral health programs; personnel; fingerprinting requirements; exemptions; definitions 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.

evidence: Based on record review and interview, the children's behavioral health program personnel failed to certify and notarize on forms provided by the department they were not awaiting trial on or had never been convicted of or admitted in open court or pursuant to a plea agreement to committing any of the offenses listed in section 41-1758.03, subsection B or C in this state or similar offenses in another state or jurisdiction. The deficient practice posed a risk if E6 was a danger to a vulnerable population.

findings: 1. A review of E6's personnel record revealed a notarized form provided by the department certifying E1 was not awaiting trial on or had never been convicted of or admitted in open court or pursuant to a plea agreement to committing any of the offenses listed in section 41-1758.03, subsection B or C in this state or similar offenses in another state or jurisdiction was not available for review. 2. In an interview, E1 acknowledged E6 had not certified on notarized forms they were not awaiting trial on or had never been convicted of or admitted in open court or pursuant to a plea agreement to committing any of the offenses listed in section 41-1758.03, subsection B or C in this state or similar offenses in another state or jurisdiction.

evidence: Based on documentation review, record review, and interview, the health care institution failed to develop and administer an initial training and continued competency training program in fall prevention and fall recovery. The deficient practice posed a risk if staff were unable to safely assist a resident who's fallen.

findings: 1. A review of facility documentation revealed a policy and procedure to cover fall prevention and fall recovery was not available for review. 2. A review of E1's, E2's, E3's, E5's, E6's, and E7's personnel records revealed documentation of training in fall prevention and fall recovery was not available for review. 3. In an interview, E1 acknowledged the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery. This is a repeat deficiency from the complaint and compliance inspection conducted on March 6, 2023.

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

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

findings: 1. A review of the facility's policies and procedures revealed a policy titled, "Training Plan/Policy." The policy stated, " ... 6. Specific Trainings: 1. CPR and First Aid: 1) Personnel Requirements... 1) Personnel should have CPR and First Aid certification prior to providing direct services to clients... 6) Cover CPR Training including: a. The method and content of CPR training, which includes a demonstration of the individual's ability to perform CPR training. All employees will receive CPR training from an approved course instructor; 7) Employees will get CPR training from an approved agency such as Red Cross, ASHI, Heart Savers, Certified Emergency Training of Arizona, etc..." 2. A review of E5's personnel record revealed documentation of CPR training from "National Health & Safety Association" issued December 2, 2022 and valid until December 2, 2024. 3. A review of the "National Health & Safety Association" website revealed courses were conducted online. The "National Health & Safety Association" website stated "Online CPR certification made easy." 4. A review of the facility's electronic daily staffing schedules revealed schedules dated from April 28, 2024 to May 4, 2024. The daily staffing schedules revealed E5 was scheduled to work alone on the following dates and times: - April 28, 2024 from 6AM-6PM - April 29, 2024 from 6AM-6PM - April 30, 2024 from 6AM-6PM - May 1, 2024 from 6AM-6PM - May 2, 2024 from 6AM-6PM - May 3, 2024 from 6AM-6PM - May 4, 2024 from 6AM-6PM 5. In an interview, E1 acknowledged E5's CPR training did not include a demonstration of the individual's ability to perform CPR and the policy and procedure was not implemented.

rule: C. An administrator shall ensure that: 1. Policies and procedures are established, documented, and implemented to protect the health and safety of a resident that: m. Cover medical records, including electronic medical records;

evidence: Based on documentation review and interview, the administrator failed to ensure policies and procedures were established to cover medical records, including electronic medical records. The deficient practice posed a risk if staff were unable to provide documentation during a disaster or medical emergency.

findings: 1. A review of facility documentation revealed a policy and procedure titled, " Medical Records Content." The policy stated, "... IV. PROCEDURE: A: A resident record shall not contain information about another client or individual unless the information impacts the treatment of the client; B: All entries into the medical record are in ink..." 2. In an interview, E1 reported resident medical records were kept in a physical file and electronic medical record. 3. In an interview, E1 acknowledged policies and procedures were not established to include electronic medical records.

evidence: Based on documentation review and interview, the administrator failed to ensure policies and procedures were reviewed at least once every three years and updated as needed.

findings: 1. A review of facility documentation revealed a policy and procedure titled, " Policy and Procedure Review." The policy stated, " I. PROCEDURE: To ensure personnel member review policies and procedures when revised, updated and/or created. Will be reviewed and, if applicable, updated at least once every 24 months. Policies and procedures will be reviewed and, if applicable, updated by the administrator and/or program director annually..." However, documentation of the policy and procedure review was not available for review. 2. In an interview, E1 acknowledged the administrator failed to ensure policies and procedures were reviewed and updated as necessary.

rule: C. An administrator shall ensure that: 5. Unless otherwise stated: a. Documentation required by this Article is provided to the Department within two hours after a Department request; and

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure documentation required by Article 7 was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance.

findings: 1. The Compliance Officer's arrived at the facility at 10:15 AM. 2. The Compliance Officer's requested to review the following documentation at 10:30 AM: - Staffing schedules for the last 12 months - Three medical records with medication administration records and medication orders - Seven personnel records - Policies and procedures - Disaster plan 3. The Compliance Officer's, at 12:15 PM, had not been provided the following documentation: - Medication administration records - Staffing schedule - Disaster Plan - E5's criminal history affidavit - Clinical oversight 4. In an interview, E1 acknowledged documentation required by Article 7 was not provided to the Department within two hours after a Department request. This is a repeat deficiency from the complaint and compliance inspection conducted on March 6, 2023.

rule: M. An administrator shall ensure that the following information or documents are conspicuously posted on the premises and are available upon request to a personnel member, employee, resident, or a resident's representative: 2. The location at which inspection reports required in R9-10-720(C) are available for review or can be made available for review, and

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

findings: 1. The Compliance Officer's observed several posting around the facility, however, a posting stating the location where inspection reports could be made available for review was not conspicuously posted. 2. In an interview, E1 acknowledged the administrator failed to ensure a posting for inspection reports was posted on the premises.

rule: M. An administrator shall ensure that the following information or documents are conspicuously posted on the premises and are available upon request to a personnel member, employee, resident, or a resident's representative: 3. The calendar days and times when a resident may accept visitors or make telephone calls.

evidence: Based on observation and interview, the administrator failed to ensure the calendar days and times when a resident may accept visitors or make telephone calls was conspicuously posted on the premises. The deficient practice posed a risk if residents were unable to make necessary telephone calls or accept visitors.

findings: 1. The Compliance Officer's observed several posting in the facility. However, a posting of the calendar days and times when a resident may accept visitors or make telephone calls was not available for review. 2. In an interview, E1 acknowledged the aforementioned document was not posted.

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

evidence: Based on record review and interview, the administrator failed to ensure documentation of current contracted services included a description of the contracted services provided, for one behavioral health professional (BHP) and one registered nurse (RN) sampled. The deficient practice posed a risk as the Department was not provided contracts for the behavioral health professional or registered nurse.

findings: R9-10-101.56. "Contracted services" means medical services, nursing services, behavioral health services, health-related services, ancillary services, or environmental services provided according to a documented agreement between a health care institution and the person providing the medical services, nursing services, health-related services, ancillary services, or environmental services. 1. A review of E6's personnel record revealed E6 was hired as the BHP. However, documentation of current contracted services including a description of the contracted services provided was not available for review. 2. A review of E7's personnel record revealed E7 was hired as the RN. However, documentation of current contracted services including a description of the contracted services provided was not available for review. 3. In an interview, E1 acknowledged current contracts for E6 and E7 were not available for review.

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

evidence: Based on record review and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include the individual's starting date of employment, for one of seven personnel members sampled.

findings: 1. A review of E6's personnel record revealed E6's starting date of employment was not available for review. 2. In an interview, E1 acknowledged the required documentation was not available for review. This is a repeat deficiency from the complaint and compliance inspection conducted on March 6, 2023.

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure personnel records were maintained to include documentation of the individual's completed orientation and in-service education. The deficient practice posed a risk if a personnel member was unable to meet a resident's needs.

findings: R9-10-101.115. "In-service education" means organized instruction or information that is related to physical health services or behavioral health services and that is provided to a medical staff member, personnel member, employee, or volunteer. R9-10-101.155. "Orientation" means the initial instruction and information provided to an individual before the individual starts work or volunteer services in a health care institution. 1. A review of facility documentation revealed a policy and procedure titled, " Training Plan/Policy." The policy stated, "... 11. Documentation Requirements... 2. A tracking system is maintained to ensure training is in compliance with internal and external customers: c. Documentation of training is retained in the personnel file of all individuals..." 2. A review of facility documentation revealed a policy and procedure titled, " Training Plan/Policy." The policy stated "... 1. Orientation: a. All personnel, volunteers, students and clinical contractors are required to complete an orientation training specific to their professional requirements and job description; b. Orientation training prior to providing services which includes but are not limited to: a) Agency policies and procedures; b) Client Rights; c) Safety-evacuation path; d) Procedures responding to a fire, disaster, a hazard and a medical emergency; e) Immediately report suspected or alleged abuse, neglect or exploitation or a violation of a client's rights and incident reporting; f) Identifying the location of client record and how client records and information are protected; c. Facility orientation training is completed during the first week of employment; d. Skills and knowledge related to personnel job description prior to providing services; e. All RN, Behavioral Health Technicians/paraprofessional registry contractors and temp to-hire contractors shall have orientation training; f. Personnel shall complete orientation and training specific to their job..." 3. A review of R2's medical record revealed a medication administration record (MAR) dated April 2024. E1's and E3's name and initials under the staff column as personnel who provided assistance in the self-administration of medication. 4. A review of E1's and E3's personnel records revealed documentation of assistance in the self-administration of medication training was not available for review. 5. A review of E6's personnel record revealed documentation of completed orientation was not available for review. 6. In an interview, E1 acknowledged documentation of in-service education was not provided for review for E1 and E3 and E6's completed orientation was not available for review. This is a repeat deficiency from the complaint and compliance inspection conducted on March 6, 2023.

rule: G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes: 3. Documentation of: 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 to include documentation of A.R.S. \'a7 36-411(C)(1)(2), for two of seven personnel members sampled.

findings: A.R.S. \'a7 36-411(C)(1)(2) Owners shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency; 2. Verify the current status of a person's fingerprint clearance card. 1. A review of E6's personnel record revealed a valid fingerprint clearance card. However, documentation of compliance with A.R.S. \'a7 36-411(C)(2) was not available for review. 2. A review of E7's personnel record revealed a valid fingerprint clearance card. However, documentation of compliance with A.R.S. \'a7 36-411(C)(1)(2) was not available for review. 3. In an interview, E1 acknowledged E6's and E7's A.R.S. \'a7 36-411(C)(1)(2) documentation was not included in the personnel records. This is a repeat deficiency from the complaint and compliance inspection conducted on March 6, 2023.

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure at least one personnel member was present at the behavioral health residential facility during hours of operation who had cardiopulmonary resuscitation (CPR) training. The deficient practice posed a risk if E5 was unable to meet a resident's needs during an emergency or an accident.

findings: 1. A review of the facility's policies and procedures revealed a policy titled, "Training Plan/Policy." The policy stated "... 6. Specific Trainings: 1. CPR and First Aid... 1) Personnel should have CPR and First Aid certification prior to providing direct services to clients. Personnel may provide direct service prior to obtaining CPR and First Aid certification as long as they do not work alone on a shift... a) In the event a personnel member does not complete the required CPR/First Aid training, the employee shall be suspended without pay until confirmation of the training is submitted to their supervisor..." 2. A review of E5's personnel record revealed documentation of CPR training from "National Health & Safety Association" issued December 2, 2022 and valid until December 2, 2024. 3. A review of the "National Health & Safety Association" website revealed courses were conducted online. The "National Health & Safety Association" website stated "Online CPR certification made easy." 4. A review of the facility's electronic daily staffing schedules revealed schedules dated from April 28, 2024 to May 4, 2024. The daily staffing schedules revealed E5 was scheduled to work alone on the following dates and times: - April 28, 2024 from 6AM-6PM - April 29, 2024 from 6AM-6PM - April 30, 2024 from 6AM-6PM - May 1, 2024 from 6AM-6PM - May 2, 2024 from 6AM-6PM - May 3, 2024 from 6AM-6PM - May 4, 2024 from 6AM-6PM 5. In an interview, E1 acknowledged at least one personnel member was not present at the behavioral health facility during hours of operation who had CPR training to include a demonstration.

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

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

findings: 1. A review of facility documentation revealed daily staffing schedules dated from January 1, 2024 to April 28, 2024. However, the staffing schedules did not include the on-call behavioral health professional (BHP). 2. In an interview, E1 acknowledged the daily staffing schedule did not include the on-call BHP.

rule: C. An administrator shall ensure that a resident's medical record contains: 6. If applicable, documented general consent and informed consent for treatment by the resident or the resident's representative;

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a resident's medical record contained documentation of general consent and informed consent for treatment by the resident or resident's representative, for one of three residents sampled. The deficient practice posed a risk if the Department was unable to ensure behavioral health services were being provided to resident's as needed.

findings: 1. A review of facility documentation revealed a policy and procedure titled, "Medical Records Content." The policy stated, "... III. POLICY: LIFE IS A CIRCLE YOUTH AND FAMILIES SERVICES medical records shall be kept in a consistent and organized format. The record contains client-specific information, as appropriate to the care, treatment and services provided at LIFE IS A CIRCLE YOUTH AND FAMILIES SERVICES..." 2. A review of R3's medical record revealed documentation of general consent and informed consent for treatment was not available for review. 3. In an interview, E1 reported the documentation was somewhere on-site but reported being nervous about the inspection and was unable to find the documentation.

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

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a resident's medical record contained medication orders, for two of three residents sampled. The deficient practice posed a risk if the Department was unable to ensure behavioral health services were being provided to resident's as needed.

findings: 1. A review of facility documentation revealed a policy and procedure titled, "Medical Records Content." The policy stated, "... III. POLICY: LIFE IS A CIRCLE YOUTH AND FAMILIES SERVICES medical records shall be kept in a consistent and organized format. The record contains client-specific information, as appropriate to the care, treatment and services provided at LIFE IS A CIRCLE YOUTH AND FAMILIES SERVICES..." 2. A review of R1's medical record revealed documentation of medication orders were not available for review. 3. A review of R2's medical record revealed documentation of medication orders were not available for review. 4. In an interview, E1 reported the documentation was somewhere on-site but reported being nervous about the inspection and was unable to find the documentation.

rule: C. An administrator shall ensure that a resident's medical record contains: 11. Assessment;

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a resident's medical record contained a nursing assessment and behavioral health assessment, for two of three residents sampled. The deficient practice posed a risk if the Department was unable to ensure behavioral health services were being provided to resident's as needed.

findings: 1. A review of facility documentation revealed a policy and procedure titled, "Medical Records Content." The policy stated, "... III. POLICY: LIFE IS A CIRCLE YOUTH AND FAMILIES SERVICES medical records shall be kept in a consistent and organized format. The record contains client-specific information, as appropriate to the care, treatment and services provided at LIFE IS A CIRCLE YOUTH AND FAMILIES SERVICES..." 2. A review of R1's medical record revealed documentation of a nursing assessment and behavioral health assessment were not available for review. 3. A review of R2's medical record revealed documentation of a nursing assessment and behavioral health assessment were not available for review. 4. In an interview, E1 reported the documentation was somewhere on-site but reported being nervous about the inspection and was unable to find the documentation.

rule: C. An administrator shall ensure that a resident's medical record contains: 12. Treatment plans;

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a resident's medical record contained a treatment plan, for two of three residents sampled. The deficient practice posed a risk if the Department was unable to ensure behavioral health services were being provided to resident's as needed.

findings: 1. A review of facility documentation revealed a policy and procedure titled, " Medical Records Content." The policy stated, "... III. POLICY: LIFE IS A CIRCLE YOUTH AND FAMILIES SERVICES medical records shall be kept in a consistent and organized format. The record contains client-specific information, as appropriate to the care, treatment and services provided at LIFE IS A CIRCLE YOUTH AND FAMILIES SERVICES..." 2. A review of R1's medical record revealed documentation of a treatment plan was not available for review. 3. A review of R2's medical record revealed documentation of a treatment plan was not available for review. 4. In an interview, E1 reported the documentation was somewhere on-site but reported being nervous about the inspection and was unable to find the documentation.

rule: 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. The deficient practice posed a risk to resident's if staff were unable to adequately assist with medication services.

findings: 1. A review of facility documentation revealed a policy and procedure titled, " Assistance in the Self-Administration of Medication." However, documentation of a medical practitioner or registered nurse reviewing and approving the policies and procedure was not available for review. 2. In an interview, E1 acknowledged 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. This is a repeat deficiency from the complaint and compliance inspection conducted on March 6, 2023.

rule: B. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, a registered dietitian or director of food services shall ensure that: 2. A food menu: c. Is conspicuously posted at least one calendar day before the first meal on the food menu will be served,

evidence: Based on observation and interview, the administrator failed to ensure a food menu was conspicuously posted at least one calendar day before the first meal on the food menu will be served. The deficient practice posed a risk to the health and safety of residents if residents were unable to ensure their dietary restrictions and requirements.

findings: 1. The Compliance Officer's observed a facility food menu posted on the refrigerator titled, " Week Two: Life Is A Circle." However, the month, dates, and year of the menu was not documented. 2. In an interview, E1 acknowledged the administrator failed to ensure the food menu was posted at least one calendar day before the first meal.

rule: B. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, a registered dietitian or director of food services shall ensure that: 3. Meals and snacks provided by the behavioral health residential facility are served according to posted menus;

evidence: Based on observation and interview, the administrator failed to ensure meals and snacks provided by the behavioral health residential facility were served according to the posted menu. The deficient practice posed a risk to the health and safety of residents if residents were unable to ensure their dietary restrictions and requirements.

findings: 1. The Compliance Officer's observed a facility food menu posted on the refrigerator titled, " Week Two: Life Is A Circle." Further review of the menu revealed breakfast, lunch, and dinner options, however, snacks were not documented. 2. In an interview, E1 acknowledged the administrator failed to ensure the food menu documented the snacks served by the facility.

rule: C. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that food is obtained, prepared, served, and stored as follows: 4. A refrigerator contains a thermometer, accurate to plus or minus 3° F, placed at the warmest part of the refrigerator;

evidence: Based on observation and interview, the administrator failed to ensure a refrigerator contained a thermometer, accurate to plus or minus 3\'b0 F, placed at the warmest part of the refrigerator. The deficient practice posed a risk if residents were unable to ensure adequate food conditions.

findings: 1. The Compliance Officer's observed a thermometer in the facility refrigerator, however, the thermometer appeared to not be in working condition. 2. In an interview, E1 reported the thermometer was no longer working and needed to replace it. 3. In an interview, E1 acknowledged the administrator failed to ensure a working thermometer was placed at the warmest part of the refrigerator.

rule: C. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that food is obtained, prepared, served, and stored as follows: 5. Frozen foods are stored at a temperature of 0° F or below; and

evidence: Based on observation and interview, the administrator failed to ensure frozen foods were stored at a temperature of 0\'b0 F or below. The deficient practice posed a risk if residents were unable to ensure adequate food conditions.

findings: 1. The Compliance Officer's observed a facility freezer. However, a thermometer to ensure adequate food conditions was within the freezer. 2. In an interview, E1 reported the food was frozen but did not know the temperature within the freezer. 3. In an interview, E1 acknowledged the administrator failed to ensure frozen foods were stored at a temperature of 0\'b0 F or below.

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

evidence: Based on documentation review and interview, the administrator failed to ensure the disaster plan required in subsection (B)(1) was reviewed at least once every 12 months. The deficient practice posed a risk if staff were unable to ensure the health and safety of resident's during a disaster.

findings: 1. A review of facility documentation revealed a undated policy and procedure titled, " Safety/Disaster Plan." However, documentation of the facility's annual disaster plan review was not available for review. 2. In an interview, E1 acknowledged the administrator failed to ensure the disaster plan was reviewed at least once every 12 months. This is a repeat deficiency from the complaint and compliance inspection conducted on March 6, 2023.

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

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

findings: 1. The Compliance Officer's observed stainless steel grab bars in two bathrooms in the facility. 2. In an interview, E1 acknowledged the administrator failed to ensure the premises was free from a condition which may cause a resident to suffer physical injury.

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

evidence: Based on observation and interview, the administrator failed to ensure poisonous or toxic materials were locked and inaccessible to residents. The deficient practice posed a risk to the health and safety of residents.

findings: 1. The Compliance Officer's observed a bottle of "Easy-Off" oven cleaner under the facility kitchen sink. 2. In an interview, E1 acknowledged the administrator failed to ensure poisonous or toxic materials were inaccessible to residents. This is a repeat deficiency from the complaint and compliance inspection conducted on March 6, 2023.

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

evidence: Based on observation and interview, the administrator failed to ensure a bathroom contained paper towels in a dispenser or a mechanical air hand dryer. The deficient practice posed a risk if residents were unable to ensure personal hygiene.

findings: 1. The Compliance Officer's observed an empty paper towel holder in the facility bathroom. 2. In an interview, E1 acknowledged the administrator failed to ensure a bathroom contained paper towels.

evidence: Based on observation and interview, the administrator failed to ensure a resident bedroom had a door which opened into a hallway, common area, or outdoors. The deficient practice posed a risk if residents were unable to ensure their privacy.

findings: 1. The Compliance Officer's observed a resident bedroom, next to the administrators office, with no door or door cover. 2. In an interview, E1 reported the residents broke the door cover. 3. The Compliance Officer's observed E1 hanging a door cover, however, the cover did not provide full privacy. 4. In an interview, E1 acknowledged the administrator failed to ensure a resident bedroom provided privacy.

rule: B. An administrator shall ensure that: 8. A resident bedroom complies with the following: k. Has a clothing rod or hook in the bedroom designed to minimize the opportunity for a resident to cause self-injury.

evidence: Based on observation and interview, the administrator failed to ensure a resident bedroom had a clothing rod or hook designed to minimize the opportunity for a resident to cause self-injury. The deficient practice posed a risk to residents if residents were able to cause self-injury.

findings: 1. The Compliance Officer's observed clothing hooks in a shared resident bedroom closet, located near the administrators office. 2. In an interview, E1 reported the hooks provided hanging space. 3. In an interview, E1 acknowledged the administrator failed to ensure a hook designed to minimize the opportunity for self-injury was installed.


summary: Change of Service - 5/30/2023 - 6/12/2023

raw_content: No deficiencies were found during the off-site inspection to modify the facility's licensed population, from adults to children, conducted on May 30, 2023 and completed on June 12, 2023.

inspection_type: Change of Service


facility_name: AVERY'S HOUSE

summary: Complaint - 9/5/2024

raw_content: An on-site investigation of complaint AZ00215510 was conducted on August 5, 2024 and no deficiencies were cited.


summary: Other - 5/28/2024

raw_content: No deficiencies were found during the off-site modification inspection to change the name from Springboard Counseling Services to Springboard Counseling Services dba Avery's House completed on May 28, 2024.

inspection_type: Other


summary: Change of Service - 12/5/2023 - 12/20/2023

raw_content: No deficiencies were found during the on-site inspection to modify the facility license from adults to children conducted on December 5, 2023, and off-site documentation review completed on December 20, 2023.


summary: Compliance (Annual) - 4/17/2023

raw_content: Based on Arizona Revised Statutes \'a7 36-424(B) and Arizona Administrative Code R9-10-109(E), the Department may accept an accreditation report in lieu of an onsite compliance inspection during the time of the accreditation report. The licensee submitted to the Department the current accreditation report from The Joint Commission valid from May 15, 2021, through May 14, 2024. If the health care institution's accreditation report is not valid for the entire licensure period, the Department may conduct a compliance inspection of the health care institution during the time period the department does not have a valid accreditation report for the health care institution.


facility_name: SUNFLOWER LIVING LLC

summary: Complaint;Compliance (Annual) - 2/2/2026

raw_content: The following deficiencies were found during the on-site compliance inspection and investigation of complaint 00157774 conducted on February 2, 2026:

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 and interview, the administrator failed to ensure the health care institution established, documented, and implemented tuberculosis infection control activities consistent with CDC recommendations, including annual tuberculosis education for personnel.

findings: 1. In a documentation review, no policies or procedures were available addressing tuberculosis training and education being required for personnel members. 2. In a record review of personnel files for E1, E2, E3, E4, and E5, no documentation of annual tuberculosis education or training related to recognizing the signs and symptoms of tuberculosis. 3. In an interview, E1 reported being unaware of the requirement to provide annual tuberculosis education and confirmed that tuberculosis-related policies and procedures had not been implemented. 4. In an interview, E1 stated that policies and procedures addressing tuberculosis infection control and required education would be developed and implemented. 5. In an exit interview with E1, the findings were reviewed. No additional documents or comments were provided.