summary: Complaint;Compliance (Annual) - 8/20/2025

raw_content: The following deficiencies were found during the on-site compliance inspection and investigation of complaint 00141006 conducted on August 20, 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 member to include documentation of the individual's compliance with the requirements in A.R.S. § 8-804(C), for one of six personnel members sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance.

findings: A.R.S. 8-804(C). "C. Licensees that do not contract with the state and that employ persons who provide direct services to children pursuant to title 36, chapter 7.1 must submit to the department of child safety in a manner prescribed by the department of child safety information necessary to conduct central registry background checks. The department of health services shall verify whether licensees, pursuant to title 36, chapter 7.1, have complied with the requirements of this subsection and any rules adopted by the department of health services to implement this subsection." 1. A review of E3's personnel record (hired 2023) revealed no documentation of a Department of Child Safety (DCS) central registry check being completed. 2. In an interview, E1 reviewed the personnel record and looked for the document. However, the DCS central registry document was not provided during the inspection. 3. In an exit interview, the findings were reviewed with E1, and no additional comments, statements, or documentation were provided regarding the findings.

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

evidence: Based on record review and interview, the administrator failed to ensure a treatment plan was developed and implemented for each resident to include the behavioral health services to be provided, for one of two resident records sampled. The deficient practice posed a risk if a resident did not receive treatment to cure, improve, or palliate their behavioral health issue at the health care institution.

findings: 1. A record of R2's (admitted 2023) medical record revealed a treatment plan dated July 2025. The treatment plan did not contain a plan for individual counseling. However, individual counseling was provided to the resident. 2. A review of counseling note documentation revealed a "Client Counseling/ Support Intervention Documentation Form" with "Counseling Type: Individual" dated August 2025. The "Plan:" stated, "This client and therapist will meet for counseling regularly while client is eligible for services with the intent to grow in interpersonal effectiveness, emotional regulation, and distress tolerance. Therapy will be given in direct correspondence to the goals outlined in the treatment plan, and progress will be measured according to those goals." However, individual counseling is not listed in the treatment plan dated July 2025. 3. In an interview, E1 reviewed the treatment plan for individual counseling and reported not seeing individual listed. 4. In an exit interview, the findings were reviewed with E1, and no additional comments, statements, or documentation were provided regarding the findings.

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

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

findings: 1. A review of R2's (admitted 2023) medication administration record revealed the medication "Desmopressin Acetate 0.2MG TB" However, no signed medication order was available for review. 2. In an interview, E1 reviewed R2's medication orders and attempted to obtain the signed medication order. However, the signed medication order was not provided during the inspection. 3. In an exit interview, the findings were reviewed with E1, and no additional comments, statements, or documentation were provided regarding the findings.

rule: R9-10-720.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 is 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 and evacuation drills. The most recent disaster drill was for a "Flood Drill" dated April 8, 2025. However, a disaster drill dated at least three months after the April, 8, 2025 drill was not available for review. 2. In an interview, E1 reviewed the documentation. No additional disaster drill documents were provided during the inspection. 3. 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 violation from the on-site compliance inspection completed on August 7, 2024.

rule: R9-10-720.C.3. Emergency and Safety Standards C. An administrator shall: 3. Maintain documentation of a current fire inspection.

evidence: Based on documentation review and interview, the administrator failed to maintain documentation of a current fire inspection report. The deficient practice posed a risk as the Department was unable to ensure the facility's compliance.

findings: 1. A review of facility documentation did not reveal a current fire inspection report. 2. In an interview, E1 looked for the fire inspection report. However, a current fire inspection report was not provided during the inspection. 3. In an exit interview, the findings were reviewed with E1, and no additional comments, statements, or documentation were provided regarding the findings.


state: AZ

facility_name: ALL ABOUT KIDS

summary: Complaint - 1/21/2025

raw_content: On April 16, 2024, the Department issued a Notice of Intent to Revoke for license BH3031. The Licensee and the Department entered into a Settlement Agreement with an execution date of June 17, 2024. An on-site investigation of complaints AZ00221694 and AZ00221854 was conducted on January 21, 2025 and the following deficiencies were cited :

inspection_type: Complaint

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

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

findings: 1. A review of R2's (admitted in March 2024) medical record revealed documentation to indicate a medical history and physical examination or nursing assessment was completed within 30 calendar days before admission or within 72 hours after admission was not available for review. 2. In an exit interview, E1 acknowledged a medical history and physical exam or a nursing assessment for R2 was not performed.

rule: A. An administrator shall ensure that: 9. Except as provided in subsection (A)(10), a behavioral health assessment for a resident is completed before treatment for the resident is initiated;

evidence: Based on record review and interview, the administrator failed to ensure a behavioral health assessment was completed before treatment for the resident was initiated, for one of two residents sampled. The deficient practice posed a risk as an analysis of the resident's needs for behavioral health services to determine which services a health care institution would provide was not completed.

findings: 1. A review of R1's (admitted in November 2024) medical record revealed a behavioral health assessment dated ten calendar days after R1's date of admission. 2. A review of R1's medical record revealed group counseling sessions, prior to the completion of R1's behavioral health assessment, on the following dates: -November 12, 2024; -November 13, 2024; -November 19, 2024; and -November 20, 2024. 3. In an exit interview, E1 acknowledged R1's behavioral health assessment was not completed before treatment was initiated.

rule: A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that: 2. Is completed: b. Before the resident receives physical health services or behavioral health services or within 48 hours after the assessment is completed;

evidence: Based on record review and interview, the administrator failed to ensure a treatment plan was developed for each resident and was completed before the resident received behavioral health services, for one of two residents sampled. The deficient practice posed a risk as a treatment plan was not developed to articulate decisions and agreements before treatment was initiated.

findings: 1. A review of R1's (admitted in November 2024) medical record revealed a treatment plan dated ten calendar days after R1's date of admission. 2. A review of R1's medical record revealed group counseling sessions, prior to the completion of R1's treatment plan, on the following dates: -November 12, 2024; -November 13, 2024; -November 19, 2024; and -November 20, 2024. 3. In an exit interview, E1 acknowledged R1's behavioral health assessment was not completed before receiving behavioral health services.

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

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

findings: 1. A review of R1's medical record revealed a treatment plan (dated in November 2024). However, the treatment plan did not include the signature of the resident's representative, and the date signed, or documentation of the refusal to sign. 2. In an exit interview, E1 acknowledged R1's treatment plan did not include the signature of the resident's representative, and date signed, or documentation of the refusal to sign.

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

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

findings: 1. A review of R2's medical record revealed an updated treatment plan dated in September 2024. The treatment plan contained a review date in December 2024. However, a reviewed and updated treatment plan was not available for review. 2. In an exit interview, E1 acknowledged R1's treatment plan had not been reviewed and updated according to the review date specified in the treatment plan.

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: 1. Food is free from spoilage, filth, or other contamination and is safe for human consumption;

evidence: Based on observation and interview, the administrator failed to ensure food was free from spoilage, filth, or other contamination and was safe for human consumption. The deficient practice posed a food-borne illness risk to residents.

findings: 1. The Compliance Officer observed "Classic Garden" lettuce in the kitchen refrigerator with an expiration date of January 13, 2025. The lettuce appeared to be spoiled. 2. In an exit interview, E1 acknowledged the food in the refrigerator was not free from spoilage.

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

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

findings: 1. The Compliance Officer observed in the kitchen, accessible to residents, the following: a broken wood panel located on the island. 2. The Compliance Officer observed in the privacy room, accessible to residents, the following: a broken window. 3. The Compliance Officer observed in a shared resident's bedroom the following: a broken window covered by a large wood panel, and what appeared to be food debris splattered on the wall. 4. The Compliance Officer observed in a shared resident's bedroom the following: holes in the wall, and missing drawers in a nightstand. 5. The Compliance Officer observed in a shared bathroom located in a shared resident's bedroom the following: broken tiles exposing sharp edges, exposed outlets missing the face cover, a missing privacy curtain, and what appeared to be vomit located near the toilet, and brownish discoloring on the floor located near the toilet. 6. The Compliance Officer observed on the exterior of the premises from the backyard, accessible to residents the following: holes in the wall, holes in a pillar structure exposing foundational wires. 7. In an interview, E1 reported all the issues were in the process of being fixed and/or looked at for repair. 8. The Compliance Officer observed two individuals arrive on-site to replace the window in the privacy room. 9. In an exit interview, E1 acknowledged the premises was not in a condition that allowed the premises to be used for the original purpose, cleaned and, and free from a condition or situation that may cause a resident or other individual to suffer physical injury.


summary: Complaint - 8/7/2024

raw_content: On April 16, 2024, the Department issued a Notice of Intent to Revoke for license BH3031. The Licensee and the Department entered into a Settlement Agreement with an execution date of June 17, 2024. The inspection found the licensee, All About Kids, to be out of compliance with the following term included in the agreement: -Term #9 - "Licensee agrees to remain in substantial compliance with A.A.C. Title 9, Chapter 10, Article 7." Per A.R.S. 36-401(46) "Substantial compliance" means that the nature or number of violations revealed by any type of inspection or investigation of a health care institution does not pose a direct risk to the life, health or safety of patients or residents. On August 7, 2024, an on-site review of the plan of correction was conducted and the following uncorrected deficiency was found:

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

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

rule: G. An administrator shall ensure that a discharge summary for a resident: 2. Includes: a. The following information authenticated by a medical practitioner or a behavioral health professional: i. The resident's presenting issue and other physical health and behavioral health issues identified in the resident's treatment plan; ii. A summary of the treatment provided to the resident; iii. The resident's progress in meeting treatment goals, including treatment goals that were and were not achieved; and iv. The name, dosage, and frequency of each medication ordered for the resident by a medical practitioner at the behavioral health residential facility at the time of the resident's discharge;

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

rule: 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

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;

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 was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees.

findings: 1. The Compliance Officer requested to review the review of the facility's disaster plan per R9-10-720.B.3 at 12:30 PM. 2. A review of facility documentation revealed an undated disaster plan. However, documentation to indicate the disaster plan was reviewed at least once every 12 months was not available for review. 3. In an interview, E1 reported the facility's disaster plan had been reviewed at least once within the last 12 months but was unable to locate the documentation.


summary: Complaint - 8/7/2024

raw_content: On April 16, 2024, the Department issued a Notice of Intent to Revoke for license BH3031. The Licensee and the Department entered into a Settlement Agreement with an execution date of June 17, 2024. The inspection found the licensee, All About Kids, to be out of compliance with the following term included in the agreement: -Term #9 - "Licensee agrees to remain in substantial compliance with A.A.C. Title 9, Chapter 10, Article 7." Per A.R.S. 36-401(46) "Substantial compliance" means that the nature or number of violations revealed by any type of inspection or investigation of a health care institution does not pose a direct risk to the life, health or safety of patients or residents. On August 7, 2024, an on-site review of the plan of correction was conducted and the following uncorrected deficiency was cited:

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 record review, documentation 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 requested to review the review of the facility's disaster plan per R9-10-720.B.3 at 12:30 PM. 2. A review of facility documentation revealed an undated disaster plan. However, documentation to indicate the disaster plan was reviewed at least once every 12 months was not available for review. 3. In an interview, E1 reported the facility's disaster plan had been reviewed at least once within the last 12 months but was unable to locate the documentation. 4. In an interview, E1 acknowledged documentation required by Article 7 was not provided to the Department within two hours after a Department request.

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

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

rule: D. An administrator shall ensure that there is a documented discharge order by a medical practitioner or behavioral health professional before a resident is discharged unless the resident leaves the behavioral health residential facility against a medical practitioner's or behavioral health professional's advice.


summary: Compliance (Annual) - 8/7/2024

raw_content: On April 16, 2024, the Department issued a Notice of Intent to Revoke for license BH3031. The Licensee and the Department entered into a Settlement Agreement with an execution date of June 17, 2024. The inspection found the licensee, All About Kids, to be out of compliance with the following term included in the agreement: -Term #9 - "Licensee agrees to remain in substantial compliance with A.A.C. Title 9, Chapter 10, Article 7." Per A.R.S. 36-401(46) "Substantial compliance" means that the nature or number of violations revealed by any type of inspection or investigation of a health care institution does not pose a direct risk to the life, health or safety of patients or residents. The following deficiencies were found during the on-site compliance inspection conducted on August 7, 2024:

inspection_type: Compliance (Annual)

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

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

findings: 1. A review of the facility's electronic policies and procedures revealed a policy titled "Fall Prevention and Recovery training" (dated November 20, 2023). The policy stated "...Review Arizona Fall Prevention Coalition website for updated information. Review and discuss attached 'Fall Prevention Checklist for Children.' Review and discuss 'Know when and where to get help?' Make the Home Safe Most falls happen at home..." However, the policy did not include the initial and continued competency training. 2. In an interview, E1 acknowledged a training program was not developed to include initial and continued competency training.

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

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

findings: 1. A review of R1's (admitted in October 2023) medical record revealed documentation to indicate a medical history and physical examination or nursing assessment was completed within 30 calendar days before admission or within 72 hours after admission was not available for review. 2. In an interview, E1 acknowledged a medical history and physical exam or a nursing assessment for R1 was not available for review.

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

evidence: Based on record review and interview, the administrator failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident's admission, and as specified in R9-10-113(A)(2), for two of two current residents sampled. The deficient practice posed a TB exposure risk to residents.

findings: R9-10-113.A.2.a.(i-iii) If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that: Include: For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, baseline screening, on or before the date specified in the applicable Article of this Chapter, that consists of: Assessing risks of prior exposure to infectious tuberculosis, Determining if the individual has signs or symptoms of tuberculosis, and Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1); 1. A review of R1's and R2's (both admitted in 2024) medical records revealed baseline screenings were not available for review. 2. A review of R1's medical record revealed a document from "River People Health Center" (dated October 2023). The document stated "...I ordered lab testing as requested for [R1], who is a resident in your group home. The test result is NEGATIVE for TB..." However, documentation of evidence from infectious TB as specified in R9-10-113 was not available for review. 3. In an interview, E1 acknowledged the administrator failed to ensure R1 and R2 provided evidence of freedom from infectious TB before or within seven calendar days after the resident's admission, and as specified in R9-10-113(A)(2).

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

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

findings: 1. A review of Department documentation revealed the facility's license was effective July 7, 2008. 2. A review of facility documentation revealed a daily staffing schedule for August 2024. The daily staffing schedule revealed the facility maintained two shifts: -9:00 AM to 9:00 PM; and -9:00 PM to 9:00 AM. 3. A review of the facility's documentation revealed disaster drills conducted on the follow dates and times: -January 21, 2024 at 9:30PM; -February 5, 2024 at 9:30PM; -March 25, 2024 at 9:30PM; -April 23, 2024 at 9:30PM; -May 14, 2024 at 9:30PM; and -June 30, 2024 at 9:30PM. However, documentation of disaster drills conducted on the 9:00 AM to 9:00 PM shift were not available for review. 4. In an interview, E1 acknowledged disaster drills for employees were not conducted on each shift.

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 was conducted at least once every six months on each shift. The deficient practice posed a risk if employees were unable to implement a disaster plan.

findings: 1. A review of Department documentation revealed the facility's license was effective July 7, 2008. 2. A review of facility documentation revealed a daily staffing schedule for August 2024. The daily staffing schedule revealed the facility maintained two shifts: -9:00 AM to 9:00 PM; and -9:00 PM to 9:00 AM. 3. A review of the facility's documentation revealed evacuation drills conducted on the follow dates and times: -January 15, 2024 at 9:30PM; -February 12, 2024 at 9:30PM; -March 20, 2024 at 9:30PM; -April 14, 2024 at 9:30PM; -May 26, 2024 at 9:30PM; -June 23, 2024 at 9:30PM; and -July 31, 2024 at 9:30PM. However, documentation of evacuation drills conducted on the 9:00 AM to 9:00 PM shift were not available for review. 4. In an interview, E1 acknowledged evacuation drills for employees and residents were not conducted on each shift.


summary: Complaint - 6/12/2024

raw_content: An on-site investigation of complaint AZ00211118 and AZ00211083 was conducted on June 12, 2024 and no deficiencies were cited.


summary: Complaint - 5/14/2024

raw_content: An on-site investigation of complaint AZ00210231 was conducted on May 14, 2024 and the following deficiencies were cited :

rule: A.R.S. § 36-424. Inspections; suspension or revocation of license; report to board of examiners of nursing care institution administrators and assisted living facility managers C. On a determination by the director that there is reasonable cause to believe a health care institution is not adhering to the licensing requirements of this chapter, the director and any duly designated employee or agent of the director, including county health representatives and county or municipal fire inspectors, consistent with standard medical practices, may enter on and into the premises of any health care institution that is licensed or required to be licensed pursuant to this chapter at any reasonable time for the purpose of determining the state of compliance with this chapter, the rules adopted pursuant to this chapter and local fire ordinances or rules. Any application for licensure under this chapter constitutes permission for and complete acquiescence in any entry or inspection of the premises during the pendency of the application and, if licensed, during the term of the license. If an inspection reveals that the health care institution is not adhering to the licensing requirements established pursuant to this chapter, the director may take action authorized by this chapter. Any health care institution, including an accredited hospital, whose license has been suspended or revoked in accordance with this section is subject to inspection on application for relicensure or reinstatement of license.

evidence: Based on documentation review, observation and interview, the licensee failed to provide complete acquiescence in any entry or inspection of the premises during the term of the license. The deficient practice posed a risk as such action shall be deemed as a reasonable cause to believe a substantial violation exists as the Department was unable to gain entry for 65 minutes.

findings: A.R.S. \'a7 36-427(B) If the licensee, the chief administrative officer or any other person in charge of the institution refuses to permit the department or its employees or agents the right to inspect the institution's premises as provided in section 36-424, such action shall be deemed reasonable cause to believe that a substantial violation under subsection A, paragraph 3 of this section exists. 1. A review of the Department documentation revealed the facility's perpetual license was effective on July 1, 2020. 2. The Compliance Officer arrived at the facility at 12:30 PM to conduct a complaint inspection. The Compliance Officer rang the door bell and knocked at the door. However, no one answered the door. 3. In a telephonic interview, conducted at 12:30 PM, E1 reported E1 was about an hour away and a personnel member was about 30 to 45 minutes away. 4. In a telephonic interview, conducted at 1:29 PM, E1 reported E1 was approximately 20 minutes away from BH3031. 5. The Compliance Officer observed E2 arrive on the premises at approximately 1:35 PM. 6. In an interview, E1 acknowledged the findings.

evidence: Based on record review and interview, the administrator failed to ensure a personnel member provided evidence of freedom from infectious tuberculosis (TB), as specified in Arizona Administrative Code (A.A.C.) R9-10-113(B)(2), for one of four personnel members sampled. The deficient practice posed a TB exposure risk to residents and false or misleading documentation was provided to the Department.

findings: A.A.C. R9-10-113(B)(2) A health care institution's chief administrative officer shall: 2. As part of the annual assessment of the health care institution's risk of exposure to infectious tuberculosis according to subsection (A)(2)(d), ensure that documentation is obtained for each individual required to be screened for infectious tuberculosis that: a. Indicates the individual's freedom from symptoms of infectious tuberculosis; and b. Is 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. 1. A review of E5's personnel records revealed documented evidence of freedom from infectious TB, dated in April 2022. However, a two-step TB test was not available for review. 2. A review of the evidence of freedom from infectious TB, dated in April 2022, revealed the document appeared altered as the "open date", the administered date, and "read" date had blue ink written over the year of "22" to indicate the year of "24." 3. In an interview, E1 acknowledged documented evidence of freedom from infectious TB for E5 was not available for review and false or misleading documentation was provided to the Department. This Rule was cited on January 25, 2024. A letter sent to the facility, dated February 12, 2024, stated "...the Department is not requesting a WRITTEN Plan of Correction (POC) at this time. However, the Department still requires that you make corrections to all violations noted in the SOD. Please document all corrections..."


summary: Complaint - 4/24/2024

raw_content: An on-site investigation of complaint AZ00209392 was conducted on April 24, 2024 and the following deficiency was cited :

rule: E. An administrator shall ensure that: 2. Within 24 hours after an emergency safety response is used for a resident, the following information is entered into the resident medical record: a. The date and time the emergency safety response was used; b. The name of each personnel member who used an emergency safety response; c. The specific emergency safety response used; d. The personnel member or resident behavior, event, or environmental factor that caused the need for the emergency safety response; and e. Any injury that resulted from the use of the emergency safety response;

evidence: Based on record review and interview, the administrator failed to ensure within 24 hours after an emergency safety response (ESR) was used for a resident, the following information was entered into the resident medical record: the date and time the ESR was used, the name of each personnel member who used an ESR, the specific ESR used, and any injury that resulted from the use of the ESR.

findings: 1. A review of R2's medical record revealed an incident report dated in January 2024. The incident report stated "...Suddenly client [R2] broke a tree branch from the tree and began to go after the client and hit...several times with the stick. Staff intervened and stopped client [R2] from continuing to physically attack client...[R2] started punching this staff member, kicking and trying to bite staff. For the safety of staff and other clients. [sic] Staff placed client [R2] in a therapeutic hold until client [R2] was able to calm down and show [R2] was not a threat to staff and other clients. Police arrived at the house to assist with the intervention..." However, the time the ESR was used, the name of each personnel member who used an ESR, the specific ESR used, and any injury that resulted from the use of the ESR was not available for review. 2. A review of R3's medical record revealed an incident report dated in March 2024. The incident report stated "...[R3] began to escelate [sic] and displayed physical aggression toward staff and was placed in a nonviolent therapeutic hold. Client stated [R3] was calm and wanted to sit in [R3's] room, Staff allowed client to sit in [R3's] room when [R3] became more agitated. staff then walked to answer the door when staff could hear 2 loud bangs on the wall, Staff returned to check on the client when [R3] banged [R3's] head against the wall for a 3rd time [R3] was then placed in a therapeutic hold to prevent serious injury..." However, the time the ESR was used, the specific ESR used, and any injury that resulted from the use of the ESR was not available for review. 3. In an interview, E1 acknowledged the required information was not documented related to the ESRs used for each resident.


summary: Complaint - 1/25/2024

raw_content: An on-site investigation of complaint AZ00203633 and AZ00203268 was conducted on January 25, 2024 and the following deficiencies were cited :

findings: 1. The Compliance Officer requested to review E4's complete personnel record, per R9-10-706.G.1-3 at 12:15 PM. 2. A review of E4's personnel record revealed documentation of CPR training, dated December 21, 2023 from American Red Cross. However, the CPR training card stated "Adult, Child and Baby First Aid/CPR/AED Online (Eligible for Skills Session within 90 days)." 3. In an interview, E1 reported E4 had a different CPR training which included a hands on demonstration. However, a CPR training to include a demonstration was not provided for review. 4. A review of electronic documentation, provided by E1 at 3:17 PM revealed a CPR training to include a demonstration for E4. 5. In an interview, E1 acknowledged documentation required by Article 7 was not provided to the Department within two hours after a Department request.

evidence: Based on documentation review and interview, the administrator failed to ensure if an administrator had a reasonable basis, according to A.R.S. \'a7 13-3620, to believe abuse occurred on the premises or while a resident was receiving services from a behavioral health residential facility's employee or personnel member, the administrator initiated an investigation of the suspected abuse. The deficient practice posed a risk as the licensee was unable to assess if there was an immediate health and safety concern for the other residents residing in the behavioral health residential facility.

findings: A.R.S. \'a7 13-3620(A) states 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... 1. A review of the facility's policies and procedures revealed a policy titled "Reporting Incidents" (dated November 15, 2022). The policy stated "...A required report is a situation that requires a staff member to create an incident report. Behavioral Health Residential Facilities Licensing (BRFL) must [sic] be notified of the incident dependent on the nature of the incident. BRFL must [sic] be notified in writing by submitting an incident report...If suspected Abuse, neglect, or exploitation occurred while a resident is receiving services at the facility from an employee, the administrator will...if applicable, take immediate action to stop the suspected abuse...report the suspected abuse...document the suspected abuse...any action taken according to R9-10-703(H)(1) [sic] ...Initiate an investigation of the suspected abuse...and document the following information within five working days after the report has been made...The dates, times, and description of the suspected abuse...A description of any injury to the resident related to the suspected abuse...and any change to the resident's physical, cognitive, functional, or emotional condition...the names of witnesses...The actions taken by the administrator to prevent the suspected abuse, neglect, or exploitation from occurring in the future...Program director and agency administrator will review all incident reports within 24 hours of the incident..." 2. A review of Department documentation revealed a complaint submitted to the Department on November 27, 2023. The complaint stated "...On 11/23/23, [R2] stated someone at the group home beat [R2] up and that it was an adult...[R2] stated that [R2] has scars on [R2's] face now. It is unknown if the scars are bruises or cuts. [R2] was told to tell another adult and [R2] stated that [R2] did, but that no one cares. It was stated the incident occurred on 11/22/2023." 3. A review of electronic documentation, provided by E2, revealed a forwarded email, dated January 25, 2024. The email was sent by E5 to E1. The email stated "On the above day and time, staff [E5] had just arrived on shift...Client [R2] was in [R2's] room laying on [R2's] bed. Staff sat on [R2's] bed and asked if [R2] was okay. [R2] stated that [R2] missed [R2's] mom and that [R2] was mad that [R2's] visits now were shorter on Saturday, now that [R2's] siblings didn't come to visits anymore and that made [R2] angry because [R2] felt [R2's] mom did not want to spend time with just [R2] without [R2's] siblings present. Staff processed with [R2] about understanding that [R2's] parent was trying to do the right thing and was still sad about everything that had happened. [R2] stated that [R2] didn't care about what she was going through and that [R2] was sick and tired of her excuses. Furthermore, [R2] was tired of living at this group home and was tired of staff abusing [R2]. [R2] stated that [R2] received the scratch on [R2's] face from Staff the day before but when staff reminded client [R2] that this staff spoke with client the night before about what had occurred with the AWOL and how [R2] had told staff [R2] was running in trees when staff was looking for client. Client [R2] became upset and stated that [R2] never said that and that this staff was lying. Staff gave client [R2's] space and continued to get Thanksgiving dinner ready to serve. Staff [E5] and [E2] came back to check on client [R2] who was on the phone with [R2's] uncle...stating that the staff at the group home daily abuse [R2], not feed him and caused a scratch on [R2's] cheek." 9. In an interview, E1 reported the Department of Child Safety (DCS) was called on November 24, 2023. However, documentation of the requirements in R9-10-703.I.1-6 was not available for review. 10. In an interview, E1 acknowledged the findings.

evidence: Based on record review and interview, the administrator failed to ensure a personnel member provided evidence of freedom from infectious tuberculosis (TB), as specified in Arizona Administrative Code (A.A.C.) R9-10-113(B)(2), for one of three personnel members sampled. The deficient practice posed a TB exposure risk to residents.

findings: A.A.C. R9-10-113(B)(2) states: "B. A health care institution's chief administrative officer shall: 2. As part of the annual assessment of the health care institution's risk of exposure to infectious tuberculosis according to subsection (A)(2)(d), ensure that documentation is obtained for each individual required to be screened for infectious tuberculosis that: a. Indicates the individual's freedom from symptoms of infectious tuberculosis; and b. Is 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." 1. A review of E4's personnel records revealed documented evidence of freedom from infectious TB, dated in December 2023. However, a two-step TB test was not available for review. 2. In an interview, E1 acknowledged documented evidence of freedom from infectious TB for E4 was not available for review.

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

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 cardiopulmonary resuscitation (CPR) training to include a demonstration, for one of three personnel members sampled. The deficient practice posed a risk if E4 was unable to perform CPR.

findings: 1. A review of E4's personnel record revealed documentation of CPR training, dated December 21, 2023 from American Red Cross. However, the CPR training card stated "Adult, Child and Baby First Aid/CPR/AED Online (Eligible for Skills Session within 90 days)." 2. In an interview, E1 reported E4 had a different CPR training which included a hands on demonstration. However, a CPR training to include a demonstration was not available for review. 3. A review of electronic documentation, provided by E1 at 3:17 PM revealed a CPR training to include a demonstration for E4. 4. In an interview, E1 acknowledged E4's personnel record did not include E4's current CPR training to include a demonstration. This Rule was cited on August 3, 2023. A letter sent to the facility, dated August 14, 2023, stated "...the Department requires that you make immediate corrections of violations that present a threat to the health or safety of a client, resident, patient or agency personnel. Additionally, the Department urges correction of all deficiencies at the earliest possible date."

evidence: Based on record review and interview, the administrator failed to ensure there was a documented discharge order by a medical practitioner or behavioral health professional before a resident was discharged, for one of one discharged resident who did not leave the behavioral health residential facility against a medical practitioner's or behavioral health professional's (BHP) advice.

findings: 1. A review of R1's medical record revealed a discharge summary (dated in December 2023). The document was signed by the BHP. However, a documented discharge order by a medical practitioner or behavioral professional before R1 was discharged was not available for review. 2. In an interview, E1 acknowledged R1 did not have a documented discharge order by a medical practitioner or behavioral health professional.


summary: Complaint - 10/31/2023

raw_content: An on-site investigation of complaints AZ00201964 and AZ00202041 was conducted on October 31, 2023 and the following deficiencies were cited :

rule: K. An administrator shall: 6. Establish and document the criteria for determining when a resident's absence is unauthorized, including criteria for a resident who: c. Is under the age of 18;

evidence: Based on documentation review and interview, the administrator failed to establish and document the criteria for determining when a resident's absence was unauthorized, including criteria for a resident who is under the age of 18. The deficient practice posed a risk as criteria reinforce and clarifies the health care institution's standards.

findings: 1. A review of the facility's policies and procedures revealed a policy and procedure titled "Unauthorized Absences Quality Management procedures" (dated November 15, 2022). The policy stated "Agency will conduct and complete the following. Document on the Internal Audit Checklist unauthorized absences and actions taken. Agency staff members will document the unauthorized absences in incident report and during clinical supervision agency team members will evaluate how to prevent incidents from continuing to occur. Agency will track number of unauthorized absences on yearly log. During clinical supervision agency team members will discuss client that was AWOL from the agency and discuss services that could have prevented client from leaving. Complete Incident Report / AWOL / Unauthorized Absences; Incident details..." However, the policy did not include the criteria for determining when a resident's absence was unauthorized, including criteria for a resident who is under the age of 18. 2. In a joint interview, E1 and E2 acknowledged the criteria for determining when a resident's absence was unauthorized, including criteria for a resident who is under the age of 18, was not established and documented.

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 document titled "[R1] Investigation" (undated). The document stated "[R1] went AWOL around midnight of October 15, 2023..." 2. A review of the facility's policies and procedures revealed a policy and procedure titled "Unauthorized Absences Quality Management procedures" (dated November 15, 2022). The policy stated "Agency will conduct and complete the following. Document on the Internal Audit Checklist unauthorized absences and actions taken. Agency staff members will document the unauthorized absences in incident report and during clinical supervision agency team members will evaluate how to prevent incidents from continuing to occur...During clinical supervision agency team members will discuss client that was AWOL from the agency and discuss services that could have prevented client from leaving." 3. A review of facility documentation revealed a document titled "Internal Audit Checklist" (dated March 8, 2023). However, documentation of R1's unauthorized absences and documentation of actions taken documented on an Internal Audit Checklist was not available for review. 4. A review of electronic documentation, provided by E1, revealed an email with a subject of "To Do list" (dated October 12, 2023). However, documentation of R1's unauthorized absence and documentation of actions taken documented on an Internal Audit Checklist was not available for review. 5. A review of facility documentation revealed a document titled "Clinical Oversight Form for BHT's" (dated October 30, 2023). The document stated "...Supervision Topic: Fall Prevention and CPI...We looked at Fall Prevention today. We also worked with CPI. The workers at the organization now have a good idea what to look for in fall prevention and what to do if a person falls...We also talked about CPI with the clients we see..." However, documentation to indicate R1's unauthorized absence and actions taken was not available for review. 6. In a joint interview, E1 and E2 acknowledged the facility did not evaluate and take action related to R1's unauthorized absence.

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

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of compliance with the requirements in A.R.S. \'a7 36-425.03(E), for one of three personnel members sampled. The deficient practice posed a risk if E1 was a danger to a vulnerable population.

findings: A.R.S. \'a7 36-425.03(E) states "Children's behavioral health program personnel shall certify on forms that are provided by the department and notarized that they are not awaiting trial on or have never been convicted of or admitted in open court or pursuant to a plea agreement to committing any of the offenses listed in section 41-1758.03, subsection B or C in this state or similar offenses in another state or jurisdiction." 1. A review of Department documentation revealed BH3031 was licensed as a children's behavioral health residential facility, effective July 7, 2008. 2. A review of E1's personnel record revealed documentation of compliance with A.R.S. \'a7 36-425.03(E) was not available for review. 3. In an interview, E1 reported the documentation was in another folder. However, documentation of compliance with A.R.S. \'a7 36-425.03(E) was not provided for review. 4. In a joint interview, E1 and E2 acknowledged E1's personnel record did not include documentation of compliance with A.R.S. \'a7 36-425.03(E).


summary: Complaint;Compliance (Annual) - 8/3/2023

raw_content: The following deficiencies were found during the compliance inspection and investigation of complaint AZ00194875, AZ00194897, AZ00195188, and AZ00197422 conducted on August 3, 2023:

inspection_type: Complaint;Compliance (Annual)

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 cardiopulmonary resuscitation (CPR) training, for one of ten personnel members sampled. The deficient practice posed a risk if E5 was unable to perform CPR.

findings: 1. A review of E5's (hired in 2023) personnel record revealed E5 was hired as the registered nurse and documentation of current Basic Life support (BLS) training dated September 21, 2021. However, documentation of CPR was not available for review. 2. In a joint interview, E1 and E2 acknowledged E5's personnel record did not include documentation of current CPR training.

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 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 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. The Compliance Officer Observed E2 on the premises and working alone when the Compliance Officer arrived at approximately 9:00AM. 2. The Compliance Officer observed five residents on the premises. 3. A review of E2's personnel record revealed documentation of CPR and first aid training from Heartsaver, issued on May 7, 2023 with an expiration date of May 2025. However, documentation to indicate the CPR training was specific to the population served was not available for review. 4. A review of facility documentation revealed a daily staffing schedule for July 1-31, 2023. The daily staffing schedule revealed E2 was scheduled to work alone on the following dates and times: -July 9-10, 2023 9:00AM-9:00PM. 5. A review of E3's personnel record revealed documentation of CPR and AED training from Heartsaver, issued on February 8, 2022 with an expiration date of February 2024. However, documentation to indicate the CPR training was specific to the population served was not available for review. 6. A review of facility documentation revealed a daily staffing schedule for June 1-30, 2023. The daily staffing schedule revealed E3 was scheduled to work alone on the following dates and times: -Every Thursday 9:00PM-9:00AM. 7. A review of E6's personnel record revealed documentation of adult CPR and first aid training from HSI, issued on May 19, 2023 with an expiration date of May 2025. However, the CPR training was not specific to the population served. 8. A review of E8's personnel record revealed documentation of adult CPR and first aid training from HSI, issued on May 8, 2023 with an expiration date of May 2025. However, the CPR training was not specific to the population served. 9. A review of E9's personnel record revealed documentation of adult CPR and first aid training from HSI, issued on February 6, 2023 with an expiration date of February 2025. However, the CPR training was not specific to the population served. 10. A review of E10's personnel record revealed documentation of adult CPR and first aid training from HSI, issued on January 17, 2023 with an expiration date of January 2025. However, the CPR training was not specific to the population served. 11. A review of facility documentation revealed a daily staffing schedule for July 1-31, 2023. The daily staffing schedule revealed E10 was scheduled to work alone on the following dates and times: -July 2-5, 2023 9:00PM-9:00AM; -July 9-12, 2023 9:00PM-9:00AM; -July 16-19, 2023 9:00PM-9:00AM; -July 23-26, 2023 9:00PM-9:00AM; and -July 30-31, 2023 9:00PM-9:00AM. 12. In a joint interview, E1 and E2 acknowledged at least one personnel member was not present at the behavioral health facility during hours of operation who had CPR training specific to children.

rule: G. An administrator shall ensure that a discharge summary for a resident: 2. Includes: a. The following information authenticated by a medical practitioner or a behavioral health professional: i. The resident's presenting issue and other physical health and behavioral health issues identified in the resident's treatment plan; ii. A summary of the treatment provided to the resident; iii. The resident's progress in meeting treatment goals, including treatment goals that were and were not achieved; and iv. The name, dosage, and frequency of each medication ordered for the resident by a medical practitioner at the behavioral health residential facility at the time of the resident's discharge;

evidence: Based on record review and interview, the administrator failed to ensure a discharge summary for a resident was authenticated by a medical practitioner or behavioral health professional (BHP), for one of two discharged residents sampled.

findings: R9-10-101(26) "Authenticate" means to establish authorship of a document or an entry in a medical record by: a. A written signature; b. An individual's initials, if the individual's written signature appears on the document or in the medical record; c. A rubber-stamp signature; or d. An electronic signature code. 1. A review of R1's medical record revealed a discharge summary. The document contained the requirements for a discharge summary, however, the document was not authenticated by a medical practitioner or BHP. 2. In a joint interview, E1 and E2 acknowledged R1's discharge summary was not authenticated by a medical practitioner or BHP.

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

evidence: Based on record review and interview, the administrator failed to ensure a behavioral health residential facility 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 residents did not receive continuous protective oversight.

findings: 1. A review of R2's medical record revealed an Incident Report (dated May 2023). The document stated "...Therapist observed from a camera monitor, [R2] sitting on couch next to...[R3] and appeared to quickly remove [R2's] hand left hand from [R3's] lap area...[R2] disclosed that today was not the first time [R2] has engaged in sexually inappropriate behavior with [R3]; [R2] disclosed this has happened multiple times before today but did not give details, number of frequency unknown." 2. In a joint interview, E1 and E2 acknowledged the minor residents did not receive continuous protective oversight as personnel members were not present during the incident.

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

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

findings: 1. A review of R1's medical record revealed a treatment plan (dated in May 2023). The treatment plan stated "...Attend groups to learn effective communication and coping skills to increase healthy interaction and communication...1 to 3x's weekly 2-3 hrs weekly..." 2. A review of R1's medical record revealed group counseling on the following dates: -June 6, 2023 for 1 hour; -June 7, 2023 for 1 hour; -June 13, 2023 for 1 hour; -June 20, 2023 for 1 hour; -June 21, 2023 for 1 hour; -June 28, 2023 for 1 hour; and -July 5, 2023 for 1 hour. -July 22, 2023 for 1 hour. However, documentation to indicate R1 received group counseling according to the number of hours identified in R1's treatment plan was not available for review. 3. A review of R2's medical record revealed a treatment plan (dated in February 2023). The treatment plan stated "...Attend groups to learn effective communication and coping skills to increase healthy interaction and communication...1 to 3x's weekly 2-3 hrs weekly..." 4. A review of R2's medical record revealed group counseling on the following dates: -April 17, 2023 for 1 hour; -April 24, 2023 for 1 hour; -April 25, 2023 for 1 hour; -June 27, 2023 for 1 hour; and -May 1, 2023 for 1 hour. However, documentation to indicate R2 received group counseling according to the number of hours identified in R2's treatment plan was not available for review. 5. A review of R3's medical record revealed a treatment plan (dated in June 2023). The treatment plan stated "...Attend groups to learn effective communication and coping skills to increase healthy interaction and communication...1 to 3x's weekly 2-3 hrs weekly..." 6. A review of R3's medical record revealed group counseling on the following dates: -June 29, 2023 for 1 hour; -July 5, 2023 for 1 hour; -July 11, 2023 for 1 hour; -July 12, 2023 for 1 hour; -July 18, 2023 for 1 hour; and -July 20, 2023 for 1 hour. -July 5, 2023 for 1 hour. However, documentation to indicate R3 received group counseling according to the number of hours identified in R3's treatment plan was not available for review. 7. A review of R4's medical record revealed a treatment plan (dated in June 2023). The treatment plan stated "...Attend groups to learn effective communication and coping skills to increase healthy interaction and communication...1 to 3x's weekly 2-3 hrs weekly..." 8. A review of R4's medical record revealed group counseling on the following dates: -July 5, 2023 for 1 hour; -July 11, 2023 for 1 hour; -July 12, 2023 for 1 hour; -July 18, 2023 for 1 hour; and -July 20, 2023 for 1 hour. However, documentation to indicate R4 received group counseling according to the number of hours identified in R4's treatment plan was not available for review. 9. In a joint interview, E1 and E2 acknowledged counseling was not provided according to the number of hours identified in R1's, R2's, R3's, and R4's treatment plans.

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 in the assistance in the self-administration of medication included a demonstration of the personnel member's skills and knowledge necessary to provide assistance in the self-administration of medication, identification of medication errors, and medical emergencies related to medication that required emergency medical intervention, and the process for notifying the appropriate entities when an emergency medical intervention was needed, for three of ten personnel members sampled.

findings: 1. A review of E1's personnel record revealed a document titled "CERTIFICATE OF COMPLETION...For completion of Medication Assistance Training Course" (dated January 18, 2023). However, the document did not include a demonstration of E1's skills and knowledge necessary to provide assistance in the self-administration of medication, identification of medication errors, and medical emergencies related to medication that required emergency medical intervention, and the process for notifying the appropriate entities when an emergency medical intervention was needed. 2. A review of E2's personnel record revealed a document titled "Certificate of Completion THIS ACKNOWLEDGES THAT [E2] HAS SUCCESSFULLY COMPLETED MEDICATION ADMINISTRATION TRAINING" (dated May 18, 2021). However, the document did not include a demonstration of E2's skills and knowledge necessary to provide assistance in the self-administration of medication, identification of medication errors, and medical emergencies related to medication that required emergency medical intervention, and the process for notifying the appropriate entities when an emergency medical intervention was needed. 3. A review of E10's personnel record revealed a document titled Certificate of Completion THIS ACKNOWLEDGES THAT [E10] HAS SUCCESSFULLY COMPLETED MEDICATION ADMINISTRATION TRAINING" (dated February 3, 2021). However, the document did not include a demonstration of E10's skills and knowledge necessary to provide assistance in the self-administration of medication, identification of medication errors, and medical emergencies related to medication that required emergency medical intervention, and the process for notifying the appropriate entities when an emergency medical intervention was needed. 4. In an interview, E1 acknowledged E1, E2, and E10 were not trained in the required components.

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 as a disaster plan reinforces and clarifies standards expected of employees.

findings: 1. A review of facility documentation revealed a disaster plan dated January 2, 2022. However, documentation to indicate the disaster plan was reviewed at least once every 12 months was not available for review. 2. In a joint interview, E1 and E2 acknowledged the facility's disaster plan had not been reviewed at least once within the last 12 months.


facility_name: YOUTH DEVELOPMENT INSTITUTE

summary: Complaint - 10/2/2024

raw_content: The following deficiency was found during the attempted on-site complaint investigation of complaint #AZ00216735 on October 2, 2024:

evidence: Based on observation, and interview, the licensee failed to provide complete acquiescence in any entry or inspection of the premises during the term of the license. The deficient practice posed a risk as the Department was unable to determine substantial compliance.

findings: A.R.S. \'a7 36-427(B) If the licensee, the chief administrative officer or any other person in charge of the institution refuses to permit the department or its employees or agents the right to inspect the institution's premises as provided in section 36-424, such action shall be deemed reasonable cause to believe that a substantial violation under subsection A, paragraph 3 of this section exists. 1. A review of the Department documentation revealed the facility's perpetual license was effective on June 1, 2020. 2. The Compliance Officer arrived at the facility on October 2, 2024 at 2:40 PM to conduct a compliance inspection. The Compliance Officer was not able to reach the door due to a wooden gate locked with a metal lock. The Compliance Officer contacted E1 by telephone at 2:47 PM and 2:52 PM but did not receive a response. The Compliance left the facility at 3:10 PM. 3. A review of the Department documentation revealed an email to E1 at 2:57 PM stating the Compliance Officer was not able to obtain access to the facility. E1 responded at 3:46 PM and stated " I have attempted to call at ... at 3:30 PM and was connected to your voicemail and left a message."


summary: Complaint - 7/9/2024

raw_content: An on-site investigation of complaint AZ00191811 was conducted on July 9, 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: f. Cover dispensing medication, administering medication, assistance in the self-administration of medication, and disposing of medication, including provisions for inventory control and preventing diversion of controlled substances;

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 assistance in the self-administration of medication. The deficient practice posed a risk as the facility's standards were not implemented and posed a risk if a resident experienced a change in condition due to not receiving prescribed medications.

findings: 1. A review of facility documentation revealed a policy (dated November 30, 2023), titled "Nursing & Medical Services: Medication Management: medication Self-Administration", stated "YDI shall ensure that a medication error or a client's adverse reaction to a medication is immediately reported to an nurse and recorded in the client record" and "4. Medication Errors a) In the case of a medication error staff is to immediately call the nurse at the BHIF for assessment of the client involved, and b) Complete and Incident report and Medication Error form." 2. A review of R1's medical record revealed an incident report (dated January 22, 2023). The incident report stated "On 1/22, staff noticed that the member had been out of [R1's] Abilify 5mg since Thursday 1/19. The staff member informed the nurse of [R1's] missing dosages. The nurse restocked [R1's] medication on the morning on 1/22 and received [R1's] morning dose." 3. A review of R1's medical record revealed a medication administration record (MAR) for January 2023. The MAR indicated R1 received "Abilify 5mg PO Q HS mood control." The MAR indicated R1 did not sign the MAR to indicate R1 received the medication on January 19-21, 2023. 4. In an interview E2 confirmed R1 did not receive assistance in the self-administration of medication on January 19-21, 2023. E2 confirmed the facility nurse was not informed immediately after the medication error occurred. E2 stated "the staff member responsible has been retrained." 5. In an interview, E1, E2, and E3 acknowledged the facility did not implement policies and procedures to protect the health and safety of a resident to cover assistance in the self-administration of medication.

rule: R9-10-109.Changes Affecting a License B. If a licensee intends to terminate the operation of a health care institution , the licensee shall ensure that the Department is notified in writing of: 1. The termination of the health care institution ' s operations, as required in A.R.S. § 36-422(D), at least 30 calendar days before the termination, and

evidence: Based on documentation review, record review, and interview, the licensee failed to ensure the Department was notified in writing of the termination of the health care institution's operations, as required in A.R.S. \'a7 36-422(D), at least 30 calendar days before the termination. The deficient practice posed a risk as the facility was not operating as a health care institution, and the condition of the facility posed a health and safety risk if a resident were to be admitted.

findings: A.R.S. \'a7 36-401(23) "Health care institution" means every place, institution, building or agency, whether organized for profit or not, that provides facilities with medical services, nursing services, behavioral health services, health screening services, other health-related services, supervisory care services, personal care services or directed care services and includes home health agencies as defined in section 36-151, outdoor behavioral health care programs and hospice service agencies. A.R.S. \'a7 36-422(D) If a current licensee intends to terminate the operation of a licensed health care institution or if a change of ownership is planned, the current licensee shall notify the director in writing at least thirty days before the termination of operation or change in ownership is to take place. The current licensee is responsible for preventing any interruption of services required to sustain the life, health and safety of the patients or residents. A new owner shall not begin operating the health care institution until the director issues a license to the new owner. 1. A review of Department documentation revealed the behavioral health residential facility's perpetual license (BH3061) was effective on April 24, 2020. 2. A review of R1's medical record revealed a discharge date in the year 2023. 3. A review of facility documentation revealed R1's discharge date in the year 2022. 4. In an interview, E4 stated "[R1] was discharged in 2022 and it is the same date the facility closed down." 5. In a joint interview, E3 and E4 reported the facility has been closed "over a year, almost two years" yet does not want to close the facility license.


summary: Compliance (Annual) - 7/1/2024

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 director may not accept an accrediation report in lieu of a compliance inspection of a health care institution if the health care institution has been subject to an enforcement action pursuant to section 36-427 or 36-431.01 within the year preceding the annual licensing fee anniversary date. The licensee submitted to the Department the current accreditation report from The Joint Commission, valid from February 17, 2024 through February 17, 2027. 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.


summary: Compliance (Annual) - 2/7/2024

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 director may not accept an accrediation report in lieu of a complinace inspection of a health care institution if the health care institution has been subject to an enforcement action pursuant to section 36-427 or 36-431.01 within the year preceding the annual licensing fee anniversary date. The licensee submitted to the Department the current accreditation report from The Joint Commission, valid from April 3, 2021 through April 3, 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.


summary: Complaint - 7/9/2024

raw_content: An on-site investigation of complaint AZ00212742 was conducted on July 9, 2024 and the following deficiencies were cited :

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 record review, documentation review, and interview, the administrator failed to provide a daily staffing schedule that list all the required items in R9-10-706(K)(3)(a-c). The deficient practice posed a risk as the Department was unable to ensure the facility's compliance. Findings: 1. The Compliance Officer requested a daily staffing schedule for May 2024, June 2024, and July 2024 at 10:11 AM (per R9-10-706(K)(3)(a-b)). The documentation requested was not provided. 2. In an interview, E2 and E3 reported "They are still working on it, the system takes a while". E1, E2, E3, and E4 acknowledged documentation required was not provided to the Department within two hours after a Department request.

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

evidence: Based on documention review and interview, the administrator failed to ensure a resident was treated with dignity, respect, and consideration. The deficient practice posed a risk as sexual abuse was alleged for one resident.

findings: 1. A review of facility documentation revealed an Arizona Health Care Cost Containment System (AHCCCS) incident report dated July 9, 2024 for an incident of sexual abuse reported on July 5, 2024. The report indicated suspected sexual abuse of R1 by E5. The report stated "On 7/6, the member reported to a staff member that on 7/5, a staff member has inappropriate sexual contact with [R1]." 2. In an interview, E2 confirmed the aforementioned incident that occurred on July 5, 2024. E2 reported E5 was the only personnel member working at the facility during the time of the incident. E2 reported E5 was no longer working in the faclity as of "July 2024." 3. In an interview, R1 confirmed the aforementioned incident that occurred on July 5, 2024. R1 stated "yes" when asked if E5 initiated sexual contact with R1. R1 stated "it happened July 5 around 8:30 PM in my bedroom." R1 stated "this set me back with my trauma." R1 reported E5 was no longer working at the facility. 4. In a joint interview, E1, E2, E3, and E4 acknowledged R1 was not treated with dignity, respect, and consideration.


summary: Complaint - 4/2/2024

raw_content: An on-site complaint investigation was conducted on April 2, 2024 and no deficiencies were cited.


summary: Complaint - 3/8/2024

raw_content: An on-site investigation of complaint AZ00195878 was conducted on March 8, 2024 and no deficiencies were cited.


summary: Compliance (Annual) - 2/7/2024

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 director may not accept an accrediation report in lieu of a complinace inspection of a health care institution if the health care institution has been subject to an enforcement action pursuant to section 36-427 or 36-431.01 within the year preceding the annual licensing fee anniversary date. The licensee submitted to the Department the current accreditation report from The Joint Commission valid from April 3, 2021 through April 3, 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: THE U-TURN FOUNDATION / KEEP RIGHT

summary: Compliance (Annual) - 12/29/2025

raw_content: No deficiencies were found during the on-site compliance inspection conducted on December 29, 2025.


summary: Compliance (Annual) - 12/2/2024

raw_content: The following deficiency was found during the on-site compliance inspection conducted on December 2, 2024.

rule: 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 included the date when the resident's treatment plan would be reviewed, for three of three residents sampled. The deficient practice posed a risk as treatment plans reinforce and clarify services to be provided to a resident.

findings: 1. A review of R1's treatment plan dated in 2024 revealed the date when the resident's treatment plan would be reviewed was not available for review. 2. A review of R2's treatment plan dated in 2024 revealed the date when the resident's treatment plan would be reviewed was not available for review. 3. A review of R3's treatment plan dated in 2024 revealed the date when the resident's treatment plan would be reviewed was not available for review. 4. In an interview, E3 acknowledged R1's, R2's, and R3's treatment plans did not include the date when the treatment plans would be reviewed.


summary: Complaint;Compliance (Annual) - 11/24/2023

raw_content: The following deficiencies were found during the on-site compliance inspection and investigation of complaint AZ00201802 conducted on November 24, 2023:

rule: B. An administrator: 3. Except as provided in subsection (A)(6), designates, in writing, an individual who is present on the behavioral health residential facility's premises and accountable for the behavioral health residential facility when the administrator is not present on the behavioral health residential facility's premises.

evidence: Based on observation, documentation review, and interview, the administrator failed to designate, in writing, an individual who was present on the behavioral health residential facility's premises and accountable for the behavioral health residential facility when the administrator was not present on the behavioral health residential facility's premises. The deficient practice posed a risk as E3 was present on the premises and was not designated, in writing, to be present and accountable for the behavioral health facility when E2 was not present and accountable.

findings: 1. The Compliance Officer (CO) observed E3 and E6 were the only staff members present on the behavioral health residential facility's premises upon arrival at 12:00 pm. 2. In an interview, E3 reported to be the individual accountable for the facility when the administrator was not present on the premises. E3 stated E3 was a "PRN BHT." E3 was unsure if this designation was in written form. 3. A review of Department documentation revealed E2 was the facility's administrator. 4. The Compliance Officer observed E2 arrive at the facility at approximately 1:15 PM. 5. In an interview, the CO requested to review the written designation indicating E3 was accountable for the facility when the administrator was not present on the premises. E2 reported to be unaware of the Rule.

rule: C. An administrator shall ensure that: 2. Each counseling session is documented in a resident's medical record to include: d. The treatment goals addressed in the counseling session; and

evidence: Based on record review and interview, the administrator failed to ensure each counseling session was documented in a resident's medical record to include the treatment goals addressed in the counseling session, for three of three residents sampled. The deficient practice posed a risk if a resident did not receive treatment to cure, improve, or palliate their behavioral health issue at the health care institution.

findings: 1. A review of R1's medical record revealed R1 received individual counseling on the following dates: -October 12, 2023; -October 20, 2023; -October 27, 2023; -November 3, 2023; and -November 10, 2023. However, the treatment goals addressed for each counseling session were not available for review. 2. A review of R2's medical record revealed R2 received individual counseling on the following dates: -October 12, 2023; -October 19, 2023; -October 20, 2023; and -November 10, 2023. However, the treatment goals addressed for each counseling session were not available for review. 3. A review of R3's medical record revealed R3 received individual counseling on the following dates: -August 10, 2023; -October 27, 2023; -November 3, 2023; and -November 10, 2023. However, the treatment goals addressed for each counseling session were not available for review. 4. In an interview, E2 acknowledged the documented counseling sessions did not include the treatment goals addressed.


facility_name: ZAREPHATH, INC

summary: Compliance (Annual) - 6/16/2025

raw_content: No deficiencies were found during the on-site compliance inspection conducted on June 16, 2025.


summary: Compliance (Annual) - 4/15/2024

raw_content: No deficiencies were found during the on-site compliance inspection conducted on April 15, 2024. Based on this deficiency-free compliance inspection, the Department shall not conduct a compliance inspection for twenty-four months, according to A.R.S. \'a7 36-425(E). Subsection (E) does not prohibit the Department from enforcing licensing requirements as authorized by A.R.S. \'a7 36-424.


summary: Other - 8/2/2023

raw_content: No deficiencies were found during the off-site inspection to decrease the occupancy from eight to seven, conducted on August 2, 2023.

inspection_type: Other


summary: Compliance (Annual) - 11/20/2025

raw_content: No deficiencies were found during the on-site compliance inspection conducted on November 20, 2025.


summary: Compliance (Annual) - 10/29/2024

raw_content: No deficiencies were found during the on-site compliance inspection conducted on October 29, 2024.


summary: Compliance (Annual) - 9/13/2023

raw_content: No deficiencies were found during the on-site compliance inspection conducted on September 13, 2023. Based on this deficiency-free compliance inspection, the Department shall not conduct a compliance inspection for twenty-four months, according to A.R.S. \'a7 36-425(E). Subsection (E) does not prohibit the Department from enforcing licensing requirements as authorized by A.R.S. \'a7 36-424.


summary: Compliance (Annual) - 11/14/2025

raw_content: No deficiencies were found during the on-site compliance inspection conducted on  November 14, 2025.


summary: Complaint;Compliance (Annual) - 10/29/2024

raw_content: The following deficiencies were found during the on-site compliance inspection and investigation of complaint AZ00211993 conducted on October 29, 2024:

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

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

findings: 1. A review of the facilities policies and procedures dated August 1, 2024 revealed a section titled " Medication Services" stated " It is the policy of Zarephath to provide a safe, organized and accoutable system of medication managment to assist clients in their highest level of fucntioning by assisting with the self-administration of medication..." 2. A review of R2's medication log revealed R2 was prescribed the following medications: -Dexmethylphenidate 5 mg. 1 Cap at 8:00 AM 3. A review of R2's medication log record for the days of May 24-27 2024 revealed R2 did not receive the following medications: - Dexmethylphenidate 5 mg. 1 Cap at 8:00 AM 4. A review of R2's medical record revealed documentation titled Incident, Accident or Death Report dated May 28, 2024. The report stated "Staff was assisting with self-administration of medication and grabbed the wrong client's med log. Staff provided R2 with 20 MG of Dexmethylphenidate instead of R2's usual dosage of 5 MG...." 5. In an interview E5 confirmed a medication error had occured, and R2 received the wrong medication. 6. In an interview E5 acknowledged the administrator failed to ensure assistance in the self-administration of medication provided to a resident was in compliance with an order.


summary: Compliance (Annual) - 9/13/2023

raw_content: This new Statement of Deficiencies superceds the Statement of Deficiencies sent to the licensee of September 14, 2023. No deficiencies were found during the on-site compliance inspection conducted on September 13, 2023. Based on this deficiency-free compliance inspection, the Department shall not conduct a compliance inspection for twenty-four months, according to A.R.S. \'a7 36-425(E). Subsection (E) does not prohibit the Department from enforcing licensing requirements as authorized by A.R.S. \'a7 36-424.