summary: Complaint - 7/31/2025

raw_content: The following deficiencies were found during the on-site  investigation of complaint 00137980 conducted on July 31, 2025:

rule: R9-10-703.G.2. Administration G. An administrator shall provide written notification to the Department of a resident's: 2. Self-injury, within two working days after the resident inflicts a self-injury or has an accident that requires immediate intervention by an emergency medical services provider.

evidence: Based on record review, documentation review and interview, the administrator failed to provide written notification to the Department of a resident's self-injury, within two working days after the resident inflicted a self-injury, requiring immediate intervention by an emergency medical services provider.

findings: 1. A review of R2's (admitted in 2024) medical record revealed a document titled "Incident, Accident or death report," dated in May 2025. The document stated "[R2] joined two... peers on the trampoline for morning exercise before taking a shower. After [R2] climbed on the trampoline, the two peers climbed down the trampoline leaving [R2] by [R2's] self inside the trampoline. The two peers told staff that they are avoiding [R2] because of... poor boundaries and annoyance. [R2] picked a rock and started hurting [R2's] self because the peers were avoiding [R2]. [R2's] 1:1 staff redirected [R1], to stop the self-harming act. Staff took [R2] to Mind-24/7 for safety concerns and for assessment. After assessment by the provider, [R2] was discharged back to the Group home at... Guardian and Case manager were notified of the incidence." 2. A review of Department documentation revealed no written notification to the Department regarding the aforementioned incident. 3. In an exit interview, E1 reported the facility had not contacted the Department within two working days of R2's self-injury requiring emergency medical services. E1 reported being unaware of this requirement.

rule: R9-10-708.A.6.d. Treatment Plan A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that: 6. Is reviewed and updated on an on-going basis: d. When a resident has a significant change in condition or experiences an event that affects treatment.

evidence: Based on record review and interview, the administrator failed to ensure a treatment plan was reviewed and updated when a resident experienced an event that affected treatment. The deficient practice posed a risk as a treatment plan directs the services to be provided to residents.

findings: 1. A review of R1's (admitted in 2025) medical record revealed a document titled "Incident, Accident or death report," dated in July 2025. The document stated "Staff received a phone call from member's school that the member assaulted his class teacher. School authority called the police, and the member reported to the police that he was feeling suicidal. EMR was called and the member was taken to Banner medical Center in Casa Grande where he spent 01 hrs:43 minutes. A behavioral crisis evaluation as well as drug screening was conducted, and the member was discharged back to the BHRF." 2. In an interview, E1 reported R1 had been suspended from school following the aforementioned event. 3. A review of R1's medical record revealed a treatment plan dated in July 2025. However, the treatment plan did not include the assault or suspension. 4. In an interview, the findings were discussed with E1 and E1 indicated the behavioral health professional was going to review and update the treatment plan on July 31, 2025; and no additional documentation or statements were provided.

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

evidence: Based on documentation review and interview, the administration failed to ensure policies and procedures for assistance in the self-administration of medication were reviewed and approved by a medical practitioner or registered nurse. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees.

findings: 1. A review of the facility's policies and procedures manual (dated March 26, 2025) revealed a policy titled "Medication Services." However, the policy was not reviewed and approved by a medical practitioner or registered nurse. 2. In an exit interview, E1 reported the policies and procedures for assistance in the self-administration of medication were not reviewed and signed by a medical practitioner or registered nurse. E1 reported being unaware of this requirement.

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

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

findings: 1. A review of R1’s (admitted in 2025) medical record revealed a treatment plan (dated in 2025). The treatment plan revealed R1 received assistance in the self-administration of medication. 2. A review of R1's medical record revealed a medication administration record (MAR) for July 2025. The MAR revealed the following medications were documented as provided on the following dates: Oxcabazepine 300mg tablet, July 1-30, 2025, 3 tablets bedtime; and Divalproex 250 mg tablet June 14, 2025 - July 30, 2025 "each day at 1 PM." 3. A review of R1's medical record revealed medication orders (dated July 2025) for the following medications: Oxcabazepine 300mg tab, "Take 1 tablet by mouth in the morning and 3 tablets every day at bedtime." 4. The Compliance Officer (CO) observed R1's Albuterol Sulfate "inhale 2 puffs... every 6 hours as needed...," Oxcarbazepine 300mg tab, "Take 1 tablet by mouth in the morning and 3 tablets every day at bedtime" and Divalproex 250 mg tablet, "each day at 1 PM." 5. In an interview, CO requested to review R1’s signed medication orders for Divalproex 250 mg tablets or Albuterol Sulfate. However, no orders were provided. 6. In an interview, the CO asked E1 if Oxcabazepine 300mg tablet was provided by mouth each morning. E1 reported R1 received Oxcabazepine 300mg tablet by mouth each morning. However, E1 did not provide documentation of R1 receiving Oxcabazepine 300mg, 1 tablet in the morning. 7. In an exit interview, the findings were discussed with E1, and no additional documentation or statements were provided.

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

findings: 1. A review of R1’s (admitted in 2025) medical record revealed a treatment plan (dated in 2025). The treatment plan revealed R1 received assistance in the self-administration of medication. 2. A review of R1's medical record revealed a medication administration record (MAR) for July 2025. The MAR revealed the following medications were documented as provided on the following dates: Oxcabazepine 300mg tablet, July 1-30, 2025, 3 tablets bedtime. However, Oxcabazepine 300mg, 1 tablet in the morning, was not documented. 3. A review of R1's medical record revealed medication orders (dated July 2025) for the following medications: Oxcabazepine 300mg tab, "Take 1 tablet by mouth in the morning and 3 tablets every day at bedtime." 4. In an interview, the CO asked E1 if Oxcabazepine 300mg tablet was provided by mouth each morning. E1 reported R1 received Oxcabazepine 300mg tablet by mouth each morning. 5. In an exit interview, the findings were discussed with E1, and no additional documentation or statements were provided.


state: AZ

facility_name: GLORIOUS CARE PROJECT LLC

summary: Complaint - 12/31/2024

raw_content: An on-site investigation of complaint AZ00221258 was conducted on December 31, 2024 and the following deficiencies were cited:

inspection_type: Complaint

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

evidence: Based on documentation review, record review, and interview, the administrator failed to establish and document policies and procedures to protect the health and safety of a resident to cover job descriptions to include the use of emergency safety responses for behavioral health technicians (BHTs). The deficient practice posed a health and safety risk to the residents.

findings: 1. A review of the facility's documentation revealed an incident report dated October 19, 2024. The incident report stated "What Happened? The Member was having an individual session with the therapist. The therapist asked a question and [R3] refused to answer and started throwing tantrums. The therapist requested [R3] should take a minutes break. The therapist called the next kid in for individuals and [R3] escalated. [R3] was verbally and physically aggressive to the therapist. The member was punching and kicking the door. To prevent member from self-harm the member was restrained. minutes lated [sic] the member was calm and requested for time out in [R3's] room. The therapist had a session the member and [R3] appologized [sic] for [R3's] actions." 2. A review of the facility's policies and procedures revealed a policy titled "R9-10-706. Personnel SECTION 39: Personnel Members Requirements & Verification of Qualifications, Skills & Knowledge " dated January 3, 2023. The policy stated "POLICY STATEMENT: To work at this agency, the individual must be 21 years old; and possess the knowledge, skills and experience based on the personnel member ' s job description to provide services to behavioral health residents in a residential facility. Administrator established a process for determining whether personnel member has the qualifications, training, experience, skills, and knowledge necessary to provide behavioral health services that this agency is authorized to provide, based on the employee ' s job description and o meet the treatment needs of diagnosed with behavioral health disorder; residents served at this agency...BHT - BEHAVIORAL HEALTH TECHNICIAN...Position Responsibilities: Reports to the Administrator. Provide residents with a supportive, protective living environment and protection of resident's rights. Provides counseling (groups/one on one/family) to residents with behavioral health disorder, and treatment that promotes resident dignity, independence, individuality, strengths, privacy, and choice. Assist residents to secure and maintain viable employment opportunities, accessing community services and resources. Prepare meals and provide residents with transportation to outside therapeutic services when indicated. Prepare daily progress notes on resident ' s progress and regression in direct and report services offered through the agency. Protect and maintain the confidentiality of resident ' s records and information. Assist residents in formal and informal independent and life skills In-service Education. Ensure that residents attend formal education or educational enhancement training. Coordinate and facilitate resident ' s social and recreational activities. Assure that residents take necessary medications in accordance with agency ' s assistance in the self-administration medication procedures. Able to identify types of medications commonly prescribed for mental disorders, personality disorders and substance abuse, and common side effects and adverse reactions of the medications. Assist residents in receiving the care and services specified in their treatment/care plan and in accordance with the rules set forth by the department of behavioral health services. Attending regularly scheduled personnel members In-service Education and meetings. Demonstrate ethical behaviors such as respecting residents and personnel members boundaries." However, the policies and procedures were not established and documented to include the use of an emergency safety response for BHT's. 3. A review of E2' s' personnel record revealed E2 did not have emergency safety response training. 4. In an interview, E1 reported R3 was placed in a therapeutic hold, with the emergency safety response "basket weave" technique. 5. In an exit interview, the findings were reviewed with E1 and no further statements were made.

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

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of compliance with the requirements in Arizona Revised Statutes (A.R.S.) \'a7 36-425.03(E), for three of four personnel members sampled. The deficient practice posed a risk if E2 and E3 were a danger to a vulnerable population.

findings: A.R.S. \'a7 36-425.03(A) states "Except as provided in subsections B, C and D of this section, children's behavioral health program personnel, including volunteers, shall submit the form prescribed in subsection E of this section to the employer and shall have a valid fingerprint clearance card issued pursuant to title 41, chapter 12, article 3.1 or, within seven working days after employment or beginning volunteer work, shall apply for a fingerprint clearance card." A.R.S. \'a7 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 E2's (hired in 2023) personnel record revealed E2 was hired as a behavioral health technician (BHT). E2's personnel record revealed a valid fingerprint clearance card. However, documentation of compliance with A.R.S. \'a7 36-425.03(E) was not available for review. 2. A review of E3's (hired in 2024) personnel record revealed E3 was hired as a BHT. E3's personnel record revealed documentation of compliance with A.R.S. \'a7 36-425.03(A) and A.R.S. \'a7 36-425.03(E), however, the document was not completed within seven working days after employment. 3. In an exit interview, the findings were reviewed with E1 and no further statements were made.

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

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

findings: 1. Arizona Administrative Code (A.A.C.) R9-10-101(199)" "Restraint" means any physical or chemical method of restricting a patient's freedom of movement, physical activity, or access to the patient ' s own body." 2. A review of the facility's documentation revealed an incident report dated October 19, 2024. The incident report stated "What Happened? The Member was having an individual session with the therapist. The therapist asked a question and [R3] refused to answer and started throwing tantrums. The therapist requested [R3] should take a minutes break. The therapist called the next kid in for individuals and [R3] escalated. [R3] was verbally and physically aggressive to the therapist. The member was punching and kicking the door. To prevent member from self-harm the member was restrained. minutes lated [sic] the member was calm and requested for time out in [R3's] room. The therapist had a session the member and [R3] appologized [sic] for [R3's] actions." 3. In an interview, E1 reported R3 was not restrained, and R3 was placed in a therapeutic hold, with the emergency safety response "basket weave" technique. 4. In an exit interview, the findings were reviewed with E1 and no further statements were made.

rule: E. An administrator shall ensure that: 1. An emergency safety response is: a. Only used: i. By a personnel member trained to use an emergency safety response,

evidence: Based on documentation review and interview, the administrator failed to ensure an emergency safety response was only used by a personnel member trained to use an emergency safety response. The deficient practice posed a risk to R3 who was physically restrained by a personnel member without the training required to ensure an attempted emergency safety response was completed.

findings: 1. A review of the facility's documentation revealed an incident report dated October 19, 2024. The incident report stated "What Happened? The Member was having an individual session with the therapist. The therapist asked a question and [R3] refused to answer and started throwing tantrums. The therapist requested [R3] should take a minutes break. The therapist called the next kid in for individuals and [R3] escalated. [R3] was verbally and physically aggressive to the therapist. The member was punching and kicking the door. To prevent member from self-harm the member was restrained. minutes lated [sic] the member was calm and requested for time out in [R3's] room. The therapist had a session the member and [R3] appologized [sic] for [R3's] actions." 2. A review of E2's personnel record revealed E2 did not have emergency safety response training. 3. In an interview, E1 reported R3 was not restrained, and R3 was placed in a therapeutic hold, with the emergency safety response "basket weave" technique. 4. In an exit interview, the findings were reviewed with E1 and no further statements were made.


summary: Compliance (Annual) - 11/18/2024

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on November 18, 2024.

inspection_type: Compliance (Annual)

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

evidence: Based on record review and interview, the administrator failed to ensure documentation of current contracted services was maintained to include a description of the contracted services provided, for one contracted registered dietician (RD).

findings: 1. A review of E3's personnel record revealed a contract with an expiration date of November 7, 2023. However a current contract to include a description of the contracted services was not available for review. 2. In an interview, E1 acknowledged a current contract for the RD was not available for review.

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

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

findings: A.R.S. \'a7 8-804(J) states "Before being employed in a position that provides direct services to children or vulnerable adults pursuant to subsection B, paragraphs 4, 5 and 10 and 11 or subsections C and D and E of this section, employees shall certify, under penalty of perjury, on forms that are provided by the department whether an allegation of abuse or neglect was made against them and was substantiated. The forms are confidential. If this certification does not indicate a current investigation or a substantiated report of abuse or neglect, the employee may provide direct services pending the findings of the central registry check." 1. A review of E2's (contracted July 2024) personnel record revealed E2 was a behavioral health professional. However, E2's documentation in compliance with A.R.S. \'a7 8-804 was not available for review. 2. A review of E4's (contracted September 2024) personnel record revealed E4 was a registered nurse. However, E4's documentation in compliance with A.R.S. \'a7 8-804 was not available for review. 3. A review of E6's (hired June 2023) personnel record revealed E6 was a behavioral health technician. However, E6's documentation in compliance with A.R.S. \'a7 8-804 was not available for review. 4. In an interview, E1 acknowledged E2's, E4's and E6's documentation in compliance with A.R.S. \'a7 8-804 was not available for review. E1 also acknowledged that compliance with A.R.S. \'a7 8-804 was not completed.

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: g. If the individual is a behavioral health technician, clinical oversight required in R9-10-115;

evidence: Based on record review and interview, the administrator failed to ensure a personnel record was maintained to include documentation of clinical oversight, as required in Arizona Administrative Code (A.A.C.) R9-10-115, for one of eight personnel members sampled. The deficient practice posed a risk as a behavioral health technician provided clinical services they were not licensed to provide and were without clinical oversight by a licensed behavioral health professional.

findings: A.A.C. R9-10-101.49.a.b.c.d. "Clinical oversight" means: Monitoring the behavioral health services provided by a behavioral health technician to ensure that the behavioral health technician is providing the behavioral health services according to the health care institution's policies and procedures and, if applicable, a patient's treatment plan; Providing on-going review of a behavioral health technician's skills and knowledge related to the provision of behavioral health services; Providing guidance to improve a behavioral health technician's skills and knowledge related to the provision of behavioral health services; and Recommending training for a behavioral health technician to improve the behavioral health technician's skills and knowledge related to the provision of behavioral health services. A.A.C. R9-10-115(4) A behavioral health technician receives clinical oversight at least once during each two-week period, if the behavioral health technician provides services related to patient care at the health care institution during the two-week period. 1. A review of R1's, R2's R3's, R4's, and R5's medical records revealed E7 had provided group and individual counseling to R1, R2, R3, R4, and R5. 2. A review of E7's (hired as a behavioral technician) personnel record revealed documentation of clinical oversight was not available for review. 3. In an interview, E1 acknowledged E7's personnel record was not maintained to include documentation of clinical oversight.

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

evidence: Based on 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, and first aid training, for one of three behavioral health technicians sampled. The deficient practice posed a risk if E7 was unable to meet a resident's needs during an emergency or during an accident.

findings: 1. A review of E7's (hired as a behavioral health technician) personnel record revealed documentation of CPR and first aid training. However, the training expired in August 2024. 2. In an interview, E1 acknowledged documentation of current CPR and first aid training was not available for review and was unsure if E7 had completed another CPR and first aid training.

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 one of five residents sampled. The deficient practice posed a potential 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: 2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, baseline screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1); 1. A review of R3's medical record revealed evidence of freedom from infectious TB as specified in R9-10-113(A)(2) was not available for review. 2. In an interview, E1 acknowledged the documentation for evidence of freedom from infectious tuberculosis specified in R9-10-113, was not available for review for R3.

rule: C. An administrator shall: 1. Obtain a fire inspection conducted according to the time-frame established by the local fire department or the State Fire Marshal,

evidence: Based on observation and interview, the administrator failed to obtain a fire inspection according to the time-frame by the local fire department or the State Fire Marshal. Finding include: 1. The Compliance Officer observed an expired (August 12, 2022) fire permit from the City of Casa Grande, with inspection number AH2208120946TERMIN, posted on the premises. The bottom of the inspection report stating "Annual Fire and Safety Inspection." 2. The Compliance Officer requested to review a current fire inspection report. However, a current fire inspection report was not provided for review. 3. In an interview E1 acknowledged E1 was not in compliance with R9-10-720.C.1.


summary: Complaint - 12/7/2023

raw_content: An on-site investigation of complaint AZ00203968 was conducted on December 7, 2023 and no deficiencies were cited :


summary: Complaint;Compliance (Annual) - 10/27/2023

raw_content: The following deficiencies were found during the on-site compliance inspection and investigation of complaints AZ00200702 and AZ00199270 conducted on October 27, 2023:

inspection_type: Complaint;Compliance (Annual)

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 two of two residents sampled. The deficient practice posed a risk to residents if no medical history and physical examination or nursing assessment were completed to assess a resident's needs prior to treatment.

findings: 1. A review of R1's (admitted in February 2023) medical record revealed a physical examination. However, the document was dated August 26, 2023. The document was not dated 30 calendar days before admission or within 72 hours after admission. 2. A review of R2's (admitted in May 2023) medical record revealed a physical examination dated October 7, 2022. The document was not dated 30 calendar days before admission or within 72 hours after admission. 3. In an interview, E1 acknowledged R1's and R2's physical examinations were not dated 30 calendar days before admission or within 72 hours after admission.

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

evidence: Based on documentation review and interview, the administrator failed to ensure, if a behavioral health residential facility was licensed to provide behavioral health services to individuals whose behavioral health issue limits the individuals' ability to function independently, a resident admitted to the behavioral health residential facility with limited ability to function independently received continuous protective oversight. The deficient practice posed a risk to the health and safety of R3 who was under 18 years old and required continuous protective oversight. Findings: Finding include: 1. A review of the facility's documentation, revealed two incident reports dated in October 2023. The incident reports included R3 leaving the facility without authorization and without the facility being aware of the incidents. 2. A review of R3's medial record did not include evidence a plan for continuous oversight protection had been implemented for R3 after leaving the facility the first time in October, 2023. 3. In an interview, E1 acknowledged both incidents involving R3 leaving the facility without authorization and unnoticed. E1 acknowledged R3 required continuous oversight protection after R3 left the facility without authorization the first time, in October, 2023.


facility_name: EAGLE'S NEST THUNDERBIRD BOYS & GIRLS

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

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


summary: Complaint;Compliance (Annual) - 12/30/2024

raw_content: No deficiencies were found during the on-site compliance inspection conducted on December 30, 2024:


summary: Compliance (Annual) - 2/14/2024

raw_content: The following deficiency was found during the on-site compliance inspection conducted on February 14, 2024:

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, observation and interview, the administrator failed to notify the Department within at least 30 calendar days of the termination of the health care institution's operations. The deficient practice posed a risk as the facility had not operated as a health care institution since February 6, 2023.

findings: A.R.S. \'a7 36-401(22) "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. 1. A review of Department documentation revealed the facility's license was effective on February 6, 2023. 2. The Compliance Officer observed no residents at the facility nor was the Compliance Officer provided medical records for review. 3. In an interview, E1 reported the facility had not admitted any residents since the facility became licensed. E1 reported the facility has referrals to begin accepting residents.


summary: Initial Monitoring - 6/19/2023

raw_content: No deficiencies were found during the on-site abbreviated follow-up inspection conducted on June 19, 2023.

inspection_type: Initial Monitoring


facility_name: NEW HAVEN COMMUNITIES LLC

summary: Complaint - 2/9/2026

raw_content: No deficiencies were found during the on-site investigation of complaints 00158263 and 00158492 conducted on February 9, 2026.


summary: Complaint;Compliance (Annual) - 1/13/2026

raw_content: No deficiencies were found during the on-site compliance inspection and investigation of complaint 00155859 conducted on January 13, 2026.


summary: Complaint - 12/3/2025

raw_content:
No deficiencies were found during
the on-site investigation of complaints 00147139, 00151164, 00151722, 00151762, 00151769, and 00151855 conducted on December 4, 2025.


summary: Complaint - 8/27/2025

raw_content: The following deficiency was found during the on-site investigation of complaints 00141375, 00141852, and 00141756 conducted on August 27, 2025:

rule: R9-10-703.B.3. Administration 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, an administrator failed to ensure the designated individual, in writing, 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 to the health and safety of residents as the complaint investigation was delayed by the administrator as the designated individual, who was present and was to be accountable for the behavioral health residential facility when the administrator was not present, was instructed to not allow the Department to enter immediately f or a high priority complaint and to wait for the administrator to arrive.

findings: 1. The Compliance Officers (CO) were greeted at the door by E5 at approximately 9:15 AM, who informed the Compliance Officers they would have to wait outside until E5 could contact E5's administrator. The Compliance Officers then asked for the designated administrator, an individual to be 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. E5 reported E5 was that individual, E5 could not let the COs enter, and E5 had to call the administrator. E5 returned moments later with E7 on a cell phone, who told the Compliance Officers the administrator (E3) was on their way and the Compliance Officers could not go inside to wait. 2. About five minutes later, E3 arrived at the facility and allowed the Compliance Officers into the facility. The Compliance Officers asked who the designated administrator was. E3 reported E5 was however, E5 did not have access to everything that may be needed for the inspection. 3. About an hour later, E4 arrived at the facility and reported any personnel member present at the facility was the designated administrator. 4. A review of documentation revealed a document dated April 1, 2025 and signed by E3 and E4. The document stated, "...To: [E4]...1. You are hereby appointed as the Administrator for the New Haven Communities, LLC Level II Behavioral Health Residential Facility..." 5. A review of documentation revealed a document dated April 1, 2025 and signed by E4. The document stated, "...To: Staff on Duty...1. In the absence of the Administrator, you are hereby appointed as the individual present and accountable for the New Haven Communities, LLC Level II Behavioral Health Residential Facility..." 6. In the exit interview, the findings were reviewed with E3 and E4. E4 reported the facility was advised by their attorney, and were given previous information by the Department, that they could ask the Compliance Officers to wait outside until the administrator arrived.


summary: Complaint - 5/22/2025

raw_content: An on-site investigation of complaint 00131382 was conducted on May 22, 2025, and the following deficiency was cited:

rule: R9-10-707.A.7. Admission; Assessment A. An administrator shall ensure that: 7. If a medical practitioner performs a medical history and physical examination or a nurse performs a nursing assessment on a resident before admission, the medical practitioner enters an interval note or the nurse enters a progress note in the resident's medical record within seven calendar days after admission;

evidence: Based on record review, documentation review, and interview, the administrator failed to ensure when a medical practitioner performed a medical history and physical examination or a nurse performed a nursing assessment on a resident before admission, the medical practitioner entered an interval note or the the nurse entered a progress note in the residents' medical record within seven days after admission, for one of three resident records sampled. The deficient practice posed a risk of not meeting residents' needs if no interval notes or progress notes were completed to assess a resident's needs prior to treatment.

findings: 1. A review of R1's medical record revealed a medical history and physical examination dated before R1's date of admission, performed by an outside medical practitioner. However, there was no documentation of an interval note in the resident's medical record within seven calendar days after admission. 2. In an interview, E8 reported that the aforementioned document did meet the requirements. However, no documentation of a progress note from a medical practitioner or an interval note was available. 3. A review of facility documentation revealed a policy titled "Admission; Assessment (Ref: R9-10-707)" (dated April 23, 2025). The procedure stated "H. The resident shall be required to have received: 1. A medical practitioner performs a medical history and physical examination or a registered nurse performs a nursing assessment 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..." 4. In an interview, E7 and E8 reviewed the findings, and no additional documentation or statements were provided.


summary: Complaint;Compliance (Annual) - 1/15/2025

raw_content: No deficiencies were found during the on-site compliance inspection and investigation of complaint AZ00217404 conducted on January 15, 2025.


summary: Complaint - 8/7/2024

raw_content: An on-site investigation of complaints AZ00214160 and AZ00214231 was conducted on August 7, 2024 and no deficiencies were cited.


summary: Complaint - 7/30/2024

raw_content: An on-site investigation of complaint AZ00213777 was conducted on July 30, 2024 and no deficiencies were cited.


summary: Complaint;Compliance (Annual) - 1/4/2024

raw_content: No deficiencies were found during the on-site compliance inspection and investigation of complaints AZ00204483, AZ00203733, AZ00201953, AZ00201951, AZ00201869 and AZ00200591 conducted on January 4, 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: Change of Service - 9/22/2023

raw_content: No deficiencies were found during the off-site inspection to modify the licensed occupancy from five to nine conducted on September 22, 2023.

inspection_type: Change of Service


summary: Complaint - 9/6/2023

raw_content: An on-site investigation of complaint AZ00200236 was conducted on September 6, 2023 and no deficiencies were cited.


summary: Complaint - 5/30/2023

raw_content: An on-site investigation of complaint AZ00195901 was conducted on May 30, 2023 and the following deficiencies were cited:

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

evidence: Based on documentation review and interview, the administrator failed to ensure sufficient personnel members were present on a behavioral health residential facility's premises with the qualifications, experience, skills, and knowledge necessary to ensure the health and safety of a resident. The deficient practice posed a risk as residents did not receive continuous protective oversight, and the Department was unable to determine substantial compliance during the inspection.

findings: 1. A review of facility documentation revealed a document titled "Incident/Accident/Death Report Form" dated May 26, 2023, 5:40 PM. The form reported "Type of Report: Other (specify): Self Harm/AWOL (absent without leave.) The report stated "The assigned member [R1] left he [sic] bhrf unsupervised and unauthorized and upon neighborhood patrol was found by staff. Assigned member was observed with self-harm injuries and after EMS called to assess had to be transported to the emergency room for stitches and assessment. Assigned member was discharged from emergency dept back to bhrf. Recommend staff notify assigned counselor to update on self-harm behaviors and behavior contract be implemented. No further recommendations." 2. A review of a daily staffing schedule revealed E2 was scheduled to work shifts alone, from 5 pm - 11 pm on the following days: -Monday, May 22, 2023 -Tuesday, May 23, 2023 -Wednesday, May 24, 2023 -Thursday, May 25, 2023 -Friday, May 26, 2023 3. In an interview, E1 reported R1 and R2 were in the back yard. E1 reported E2 was seated at the staff desk in the living room, with other residents in the living room, while watching R1 and R2 in the backyard. E1 reported E2 could not see the complete back yard while sitting at the desk. E1 reported R2 came into the facility to report to E2 that R1 had AWOLed out the back gate. E2 exited the front door and saw R1 leaving the facility's front yard and walking down the street. E1 acknowledged E2 could not ensure continuous protective oversight E2 was the only staff member at the facility.

evidence: Based on documentation 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, and the Department was unable to determine substantial compliance during the inspection.

findings: 1. A review of facility documentation revealed a document titled "Incident/Accident/Death Report Form" dated May 26, 2023, 5:40 PM. The form reported "Type of Report: Other (specify): Self Harm/AWOL (absent without leave.) The report stated "The assigned member [R1] left he [sic] bhrf unsupervised and unauthorized and upon neighborhood patrol was found by staff. Assigned member was observed with self-harm injuries and after EMS called to assess had to be transported to the emergency room for stitches and assessment. Assigned member was discharged from emergency dept back to bhrf. Recommend staff notify assigned counselor to update on self-harm behaviors and behavior contract be implemented. No further recommendations." 2. A review of a daily staffing schedule revealed E2 was scheduled to work shifts alone, from 5 pm - 11 pm on the following days: -Monday, May 22, 2023 -Tuesday, May 23, 2023 -Wednesday, May 24, 2023 -Thursday, May 25, 2023 -Friday, May 26, 2023 3. In an interview, E1 reported R1 and R2 were in the back yard. E1 reported E2 was seated at the staff desk in the living room, with other residents in the living room, while watching R1 and R2 in the backyard. E1 reported E2 could not see the complete back yard while sitting at the desk. E1 reported R2 came into the facility to report to E2 that R1 had AWOLed out the back gate. E2 exited the front door and saw R1 leaving the facility's front yard and walking down the street. E1 acknowledged the minor residents, admitted to the behavioral health residential facility with limited ability to function independently, did not receive continuous protective oversight.


summary: Complaint;Initial Monitoring - 5/25/2023

raw_content: No deficiencies were found during the on-site abbreviated follow-up inspection and complaint investigation of complaints AZ00195156, AZ00195157, AZ00195508 and AZ00195712, conducted on May 25, 2023.

inspection_type: Complaint;Initial Monitoring


facility_name: MATTIES CARE HOUSE LLC

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

raw_content: The following deficiencies were found during the attempted onsite compliance inspection on August 26, 2025, and the compliance inspection and complaint investigation of 00144712 conducted on September 16, 2025:

evidence: Based on observation and interview, the administrator failed to provide complete acquiescence to the Compliance Officer. A.R.S. § 36-424.C. 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.

findings: 1. The Compliance Officer attempted an on-site compliance inspection on August 26, 2025 at 8:31 AM. However, no one was at the facility. The Compliance Officer contacted E1 via text message. 2. In an interview, E1 reported via text message at 12:28 PM they could send E2 to the facility. The Compliance Officer was unable to return the facility on August 26, 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 four 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 E4's personnel record (hired 2024) revealed no documentation of a Department of Child Safety (DCS) central registry check being completed. 2. In an interview, E1 reported there was no DCS central registry check completed for E4. 3. In a joint exit interview, the findings were reviewed with E1 and E2 and no additional comments or statements were provided regarding the findings.


summary: Complaint - 10/3/2024

raw_content: An on-site investigation of complaint AZ00216422 was conducted on October 3, 2024 and no deficiencies were cited :


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

raw_content: The following deficiency was found during the on-site compliance inspection and investigation of complaint AZ00212976 and AZ00211184 conducted on July 15, 2024:

rule: B. If a behavioral health residential facility provides medication administration, an administrator shall ensure that: 3. A medication administered to a resident: a. Is administered in compliance with an order, and

evidence: Based on documentation review, record review, and interview, an administrator failed to ensure medication administered to a resident was administered 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 medication administration.

findings: 1. A review of facility documentation revealed an incident report, dated April 1, 2024. The incident report stated "Staff were getting clients in order to begin administering meds. Staff punched the medication from bubble pack into the medication cup. Staff became distracted trying to keep clients in line and not horse playing during medication. R1 looked at the medication for a second, prompting the staff to ask R1 if there was something wrong. R1 then proceeded to take the medication and the staff administered the medication by pouring the pills in the cup into R1's mouth. Staff went to prepare the next client's medication when staff noticed that staff was holding the medication for R1. Staff realized that staff had given R1 another clients medication..." 2. A review of R1's medical record revealed a signed list of medication orders dated April 5, 2024. The orders stated "Prozosin 1mg Capsule by oral every bedtime for sleep, Sertraline 100mg by oral every morning for depression, Abilify 20mg before bed for irritability/aggression. With a medication start date of January 17, 2024." 3. A review of R1's medication administration record (MAR) for the month of April 2024 revealed resident did not receive medication for Prozosin 1mg and Abilify 20mg on April 1, 2024. 4. In an interview, E1 acknowledged R1's medications were not administered in compliance with R1's medication orders.


summary: Initial Monitoring - 11/8/2023

raw_content: The following deficiencies were found during the on-site abbreviated follow-up inspection conducted on November 8, 2023:

rule: B. An administrator shall ensure that: 5. A resident bathroom provides privacy when in use and contains: a. A shatter-proof mirror, unless the resident's treatment plan allows for otherwise;

evidence: Based on observation, record review, and interview, the administrator failed to ensure a resident bathroom contained shatter-proof mirrors, unless the resident's treatment plan allowed for otherwise. The deficient practice posed a risk as R1's treatment plan did not allow for R1 to be around non-shatter-proof mirrors.

findings: 1. The Compliance Officer observed R1 and R2 occupied the master bedroom and a bathroom was observed in the master bedroom. The Compliance Officer observed a large mirror and a medicine cabinet mirror in the bathroom. However, there was no evidence to indicate the mirrors were shatter-proof. The Compliance Officer observed an acrylic sheet placed over each mirror with an adhesive strip. However, the acrylic sheet peeled back when the Compliance Officer pulled at the corners of the sheet. 2. A review of R1's (admitted in 2023) medical record revealed a behavioral health assessment (dated in 2023). The behavioral health assessment stated "[R1] endorsed hospitalization for SI approximately '4 to 5 months ago.'" 3. A review of R1's medical record revealed a current treatment plan (dated in 2023). The treatment plan stated "NO, Client is not safe around nonshatterproof glass as there is HX or SI/DTS/HI/, and high impulsivity." 4. In an interview, E1 acknowledged a resident bathroom did not contain a shatter-proof mirror, unless the resident's treatment plan allowed for otherwise.

rule: R9-10-113. Tuberculosis Screening A. If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that: 2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, baseline screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1);

evidence: Based on documentation review, record review, and interview, the chief administrative officer failed to implement tuberculosis (TB) infection control activities including baseline screening, for one seven personnel members sampled, and for one of two residents sampled. The deficient practice posed a potential TB exposure risk to residents.

findings: Arizona Administrative Code (A.A.C.) R9-10-113(B)(1)(a)(i) "A health care institution's chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specific in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: a. Documentation of a negative Mantoux skin test or other tuberculosis screening test that: i. Is recommended by the U.S. Centers for Disease Control and Prevention (CDC)." 1. A review of the CDC website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used." 2. A review of facility documentation revealed a daily staffing schedule for November 2023. The schedule revealed E6 was scheduled to work on the following dates and the following times: -4:00PM to 12:00AM: November 1, 2023; November 3, 2023; November 8-10, 2023; November 15-17, 2023; November 22-24, 2023; November 29-30, 2023; and -8:00AM to 4:00PM: November 4-5, 2023; November 11-12, 2023; November 18-19, 2023; and November 25-26, 2023. 3. A review of E6's (hired in 2023) personnel record revealed E6 was hired as a behavioral health technician. E6's personnel record revealed documentation of the individual's freedom from infectious TB. However, documentation, as part of the baseline screening per R9-10-113(A)(2)(a)(iii), of two-step testing was not available for review. 4. A review of E6's personnel record revealed documentation of baseline screening according to R9-10-113(A)(2)(a)(i)(ii) was not available for review. 5. A review of R2's (admitted in 2023) medical record revealed revealed documentation of baseline screening according to R9-10-113(A)(2)(a)(i)(ii) was not available for review. 6. In an interview, the findings were reviewed with E1 and no additional comments or statements were provided regarding the findings.


summary: Compliance (Initial) - 7/11/2023 - 8/16/2023

raw_content: No deficiencies were found during the on-site initial inspection conducted on July 11, 2023, and the off-site documentation review completed on August 16, 2023.

inspection_type: Compliance (Initial)


facility_name: BASAMI HOUSE, LLC

summary: Complaint - 4/29/2024

raw_content: An on-site investigation of complaints AZ00209595 and AZ00209606 was conducted on April 29, 2024, and the following deficiencies were cited :

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

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

findings: 1. A review of facility documentation revealed a policy and procedure titled "Fall Prevention and Fall Recovery Training" (dated August 1, 2023). The policy and procedure stated "... The training program requires initial training ... 6. All employees hired by the facility with either; supply evidence of completion of a comparable fall prevention and recovery provider meeting this policy requirement or attend training with the facility's provider." 2. A review of E6's (hired in 2024) personnel record revealed E6 was hired as a behavioral health technician. However, documentation of training in fall prevention and fall recovery was not available for review. 3. In an interview, the findings were reviewed with E3 and no additional comments or statements were provided regarding the findings.

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

evidence: Based on documentation review, record review, observation, and interview, the administrator failed to ensure at least one personnel member was present at the behavioral health residential facility during hours of operation of the behavioral health residential facility who had first-aid and cardiopulmonary resuscitation (CPR) training specific to the populations served by the behavioral health residential facility, for two of six personnel members sampled. The deficient practice posed a risk if E3 and E5 were unable to meet a resident's needs during an emergency or during an accident.

findings: 1. A review of facility documentation revealed a policy and procedure titled "CPR and First Aid - Duty to Care" (dated August 1, 2023). The policy and procedure stated " ... candidate must also be able to demonstrate the ability to perform CPR. An online CPR/First Aid course is not acceptable. ... CPR and First Aid cards must be current and valid." 2. A review of facility documentation revealed a daily staffing schedule for April 2024. The schedule revealed E3 and E5 were scheduled to work together from 2:00PM to 10:00PM on the following dates: -April 1-2, 2024; -April 5, 2024; -April 8-9, 2024; -April 12, 2024; -April 15-16, 2024; -April 19, 2024; -April 22-23, 2024; and -April 26, 2024. 3. A review of facility documentation revealed a daily staffing schedule for April 2024. The schedule revealed E3 was scheduled to work as on-call on April 14-20, 2024. 4. A review of facility documentation revealed a daily staffing schedule for April 2024. The schedule revealed E5 was scheduled to work alone on the following dates: -April 6, 2024: from 8:00AM to 10:00PM; -April 13, 2024: from 8:00AM to 10:00PM; -April 20, 2024: from 2:00PM to 10:00PM; and -April 27, 2024: from 2:00PM to 10:00PM. 5. A review of E3's (hired in 2024) personnel record revealed E3 was hired as a program manager. The personnel record revealed documentation of first-aid and CPR training (issued March 22, 2022 and expired March 22, 2024). However, documentation of current first-aid and CPR training was not available for review. 6. In an interview, E3 reported to be unaware E3's first-aid and CPR training had expired. 7. The Compliance Officer observed E3 make a phone call to schedule first-aid and CPR training. 8. In an interview, E3 reported E3 sometimes worked at BH8484 alone. 9. A review of E5's (hired in 2024) personnel record revealed E5 was hired as a behavioral health technician (BHT). E5's personnel record revealed documentation of first-aid and CPR training from "NationalCPRFoundation" issued April 5, 2024. The document stated "Valid for 2 years." 10. A review of the "NationalCPRFoundation" website revealed courses were conducted online. The "NationalCPRFoundation" website stated, "Help Save Lives Today with Your Online CPR Certification Training!" 11. In an interview, E1 acknowledged at least one personnel member was not present at the behavioral health residential facility during hours of operation of the behavioral health residential facility who had current first-aid and CPR training, to include a demonstration.

rule: A. An administrator shall ensure that: 1. The requirements in subsection (B) and the resident rights in subsection (E) are conspicuously posted on the premises;

evidence: Based on observation and interview, the administrator failed to ensure the requirements in subsection (B) and the resident rights in subsection (E) were conspicuously posted on the premises.

findings: 1. The Compliance Officer observed the following requirements in subsection (B) were conspicuously posted: "1. A resident is treated with dignity, respect, and consideration; 2. A resident is not subjected to: a. Abuse; b. Neglect; c. Exploitation; d. Coercion; e. Manipulation; f. Sexual abuse; g. Sexual assault; h. Seclusion; i. Restraint; ii. Retaliation for submitting a complaint to the Department or another entity; iii. Misappropriation of personal and private property by the behavioral health residential facility's personnel members, employees, volunteers, or students; iv. Discharge or transfer, or threat of discharge or transfer, for reasons unrelated to the resident's treatment needs, except as established in a fee agreement signed by the resident or the resident's representative; or v. Treatment that involves the denial of: vi. Food, vii. The opportunity to sleep, or viii. The opportunity to use the toilet;" However, the remaining requirements in subsection (B) were not conspicuously posted on the premises. 2. The Compliance Officer observed the resident rights in subsection (E) were not conspicuously posted. 3. The Compliance Officer observed the remaining requirements in subsection (B) and the resident rights in subsection (E) were stapled behind the aforementioned requirements in subsection (B). 4. In an interview, E1 acknowledged the remaining requirements in subsection (B) and the resident rights in subsection (E) were not conspicuously posted on the premises.

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

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

findings: 1. A review of facility documentation revealed a document titled "Incident Report Form" (dated April 7, 2024). The incident report stated " ... [R1] was cause [sic] by Basami House staff smoking weed in the house with peers. One of peer [sic] was able to bring weed to the group home and share with [R1]." 2. A review of R1's (admitted in 2024) medical record revealed a behavioral health assessment (dated in March 2024). The assessment stated " ... [R1] reported [R1] first smoked Marijuana at the age of 15 years old. [R1] reported [R1] thought it was cool and liked it. [R1] reported [R1] starting smoking more often as time progressed. [R1] reported Marijuana was never a problem and Marijuana calmed [R1] down ... [R1] reported I want to 'fix myself' 'I don't want to use drugs and alcohol' ... [R1] reported has reported [R1] is still struggling with grief and was engaging in the use of alcohol." 3. A review of R1's behavioral health assessment stated a diagnosis of " ... Secondary 305.20(F12.10) Cannabis Use Disorder, Mild" and "Tertiary 303.90(F10.20) Alcohol Use Disorder, Severe." 4. A review of R1's medical record revealed a document titled "Complete Evaluation/Biopsychosocial Assessment Social Worker" (dated in March 2024). The document stated " ... Pt shares [R1] had a lot of alcohol and smoked marijuana leading to [R1] to feel suicidal ... Pt shares [R1] uses substances 'once in a while.' Mainly alcohol and marijuana on occasion." 5. In an interview, E3 reported a search of resident's bags was conducted, however, the marijuana was not located. E3 acknowledged the administrator failed to ensure a resident did not have access to any materials to present a threat to the resident's health or safety based on the resident's documented diagnosis and treatment needs.


summary: Complaint - 4/21/2024 - 4/29/2024

raw_content: On April 29, 2024, an on-site review of the plan of correction was conducted and the following seven (7) uncorrected deficiencies were 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 documentation review, record review, and interview, the administrator failed to ensure documentation required by Article 7 was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine compliance.

findings: 1. The Compliance Officer requested, on April 29, 2024 at 9:26AM, to review the following documentation: -E1's complete personnel record to include documentation of a completed orientation; and in-service education; -E2's complete personnel record to include documentation of a completed orientation; and documentation compliance with the requirements in A.R.S. \'a7 36-425.03(G); and -The daily staffing schedule for February 2024. However, the aforementioned documentation was not provided for review within two hours after a Department request. 2. In an interview, E3 acknowledged documentation required by Article 7 was not provided to the Department within two hours after a Department request. This Rule was cited during the compliance and complaint inspection conducted on February 7, 2024. A letter, dated March 1, 2024, stated "Enclosed is a copy of the Statement of Deficiencies (SOD), which describes the violations the Department found at the facility. Because the case has been referred to the Enforcement Team, the Department is not requesting a WRITTEN Plan of Correction (POC) at this time. However, the Department still requires that you make corrections to all violations noted in the SOD."

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

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

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

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

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

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

findings: 1. A review of facility documentation revealed a policy and procedure titled "Personnel Orientation" (dated August 1, 2023). The policy and procedure stated "BHRF personnel members are required to complete and orientation and demonstrate competency in providing general resident care and services prior to working independently with residents." 2. A review of facility documentation revealed a policy and procedure titled "Fall Prevention and Recovery Training" (dated August 1, 2023). The policy and procedure stated " ... The training program requires initial training and continued competency review on an annual basis in fall prevention and fall recovery." 3. A review of E1's (hired in 2023) personnel record revealed E1 was hired as the administrator. However, documentation of completed orientation and training in fall prevention and fall recovery was not available for review. 4. In an interview, E3 reported E1 should have documentation of a completed orientation and training in fall prevention and fall recovery. 5. In an interview, the findings were reviewed with E3 and no additional comments or statements were provided regarding the findings. 6. A review of E2's (hired in 2024) personnel record revealed E2 was hired as the behavioral health professional. However, documentation of a completed orientation was not available for review. 7. In an interview, E3 acknowledged E2's personnel record was not maintained to include documentation of the individual's completed orientation. This Rule was cited during the compliance and complaint inspection conducted on February 7, 2024. A letter, dated March 1, 2024, stated "Enclosed is a copy of the Statement of Deficiencies (SOD), which describes the violations the Department found at the facility. Because the case has been referred to the Enforcement Team, the Department is not requesting a WRITTEN Plan of Correction (POC) at this time. However, the Department still requires that you make corrections to all violations noted in the SOD."

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

evidence: Based on record review and interview, the administrator failed to ensure a personnel record was maintained to include documentation of the individual's compliance with the requirements in Arizona Revised Statutes (A.R.S.) \'a7 36-425.03(E)(G), for four of six personnel members sampled. The deficient practice posed a risk if E2, E3, E5, and E6 were a danger to a vulnerable population.

findings: A.R.S. \'a7 36-425.03(E) Children's behavioral health program personnel shall certify on forms that are provided by the department and notarized that they are not awaiting trial on or have never been convicted of or admitted in open court or pursuant to a plea agreement to committing any of the offenses listed in section 41-1758.03, subsection B or C in this state or similar offenses in another state or jurisdiction. A.R.S. \'a7 36-425.03(G) Employers of children's behavioral health program personnel shall make documented, good faith efforts to contact previous employers of children's behavioral health program personnel to obtain information or recommendations that may be relevant to an individual's fitness for employment in a children's behavioral health program. 1. A review of E2's (hired in 2024) personnel record revealed E2 was hired as the behavioral health professional. E2's personnel record revealed a valid fingerprint clearance card. However, documentation of compliance with A.R.S. \'a7 36-425.03(E)(G) was not available for review. 2. A review of E2's personnel record revealed documentation of a form indicating they were 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. However, the document was not notarized. 3. In an interview, E3 acknowledged E2's personnel record was not maintained to include documentation of the individual's compliance with the requirements in A.R.S. \'a7 36-425.03(E)(G). 4. A review of E3's (hired in 2024), E5's (hired in 2024), and E6's (hired in 2024) personnel records revealed E3, E5, and E6 were hired as behavioral health technicians. E3's, E5's and E6's personnel records revealed valid fingerprint clearance cards. However, documentation of compliance with A.R.S. \'a7 36-425.03(G) was not available for review. 5. In an interview, E3 acknowledged E3's, E5's, and E6's personnel records were not maintained to include documentation of the individual's compliance with the requirements in A.R.S. \'a7 36-425.03(G). This Rule was cited during the compliance and complaint inspection conducted on February 7, 2024. A letter, dated March 1, 2024, stated "Enclosed is a copy of the Statement of Deficiencies (SOD), which describes the violations the Department found at the facility. Because the case has been referred to the Enforcement Team, the Department is not requesting a WRITTEN Plan of Correction (POC) at this time. However, the Department still requires that you make corrections to all violations noted in the SOD."

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

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

findings: 1. The Compliance Officer requested, on April 29, 2024 at 9:26AM, to review the following documentation: -The daily staffing schedule for February 2024. However, the aforementioned documentation was not provided for review within two hours after a Department request. 2. A review of facility documentation revealed a daily staffing schedule for February 2024 was not available for review. 3. In an interview, E3 reported a daily staffing schedule for February 2024 was not developed because E3 had not yet started employment at BH8484. 4. In an interview, E3 acknowledged a daily staffing schedule indicating the date, scheduled work hours, and name of each employee assigned to work, including on-call personnel members for February 2024 was not available for review. This Rule was cited during the compliance and complaint inspection conducted on February 7, 2024. A letter, dated March 1, 2024, stated "Enclosed is a copy of the Statement of Deficiencies (SOD), which describes the violations the Department found at the facility. Because the case has been referred to the Enforcement Team, the Department is not requesting a WRITTEN Plan of Correction (POC) at this time. However, the Department still requires that you make corrections to all violations noted in the SOD."

rule: A. An administrator shall ensure that: 3. Except as provided in subsection (A)(4), general consent is obtained from: a. An adult resident or the resident's representative before or at the time of admission, or b. A resident's representative, if the resident is not an adult;

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

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a treatment plan included the behavioral health services to be provided to the resident, for three of four residents sampled. The deficient practice posed a risk as a treatment plan was not developed to articulate decisions and agreements of services to be provided.

findings: 1. A review of facility documentation revealed a scope of services (dated August 1, 2023). The scope of services stated "... 3. Counseling services: Individual ... Group ... Family" 2. A review of R1's (admitted in 2024), R2's (admitted in 2024), and R4's (admitted in 2024) medical records revealed treatment plans (dated in 2024). However, R1's, R2's, and R4's treatment plans did not include whether individual counseling, group counseling, or family counseling was to be provided to R1, R2, and R4. 3. In an interview, E1 acknowledged R1's, R2's, and R4's treatment plans did not include the behavioral health services to be provided to the residents. This Rule was cited during the compliance and complaint inspection conducted on February 7, 2024. A letter, dated March 1, 2024, stated "Enclosed is a copy of the Statement of Deficiencies (SOD), which describes the violations the Department found at the facility. Because the case has been referred to the Enforcement Team, the Department is not requesting a WRITTEN Plan of Correction (POC) at this time. However, the Department still requires that you make corrections to all violations noted in the SOD."

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 date signed, or documentation of the refusal to sign, for one of four residents sampled. The deficient practice posed a risk as a treatment plan was not developed to articulate decisions and agreements of services to be provided.

findings: 1. A review of R4's (admitted in 2024) medical record revealed a treatment plan (dated in 2024). However, the signature of the resident's representative and date signed, or documentation of the refusal to sign, was not available for review. 2. In an interview, E3 reported R4's representative was present during the development of the treatment plan, however, the treatment plan was not signed. 3. In an interview, E3 acknowledged R4's treatment plan did not include the signature of the resident's representative and date signed, or documentation of the refusal to sign. This Rule was cited during the compliance and complaint inspection conducted on February 7, 2024. A letter, dated March 1, 2024, stated "Enclosed is a copy of the Statement of Deficiencies (SOD), which describes the violations the Department found at the facility. Because the case has been referred to the Enforcement Team, the Department is not requesting a WRITTEN Plan of Correction (POC) at this time. However, the Department still requires that you make corrections to all violations noted in the SOD."

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

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

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

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

evidence: Based on documentation review, record review, and interview, the chief administrative officer failed to implement tuberculosis (TB) infection control activities including baseline screening consisting of the individual's freedom from infectious TB, for three of six personnel members sampled. The deficient practice posed a potential TB exposure risk to residents.

findings: Arizona Administrative Code (A.A.C.) R9-10-113(B)(1)(a)(i) A health care institution's chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specific in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: a. Documentation of a negative Mantoux skin test or other tuberculosis screening test that: i. Is recommended by the U.S. Centers for Disease Control and Prevention (CDC). A.A.C. R9-10-113(B)(1)(b) A health care institution's chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specified in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: b. If the individual had a history of tuberculosis or documentation of latent tuberculosis infection, as defined in A.A.C. R9-6-1201, compliance with subsection (A)(2)(b). A.A.C. R9-10-113(A)(2)(b)(ii) If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that: 2. Include: b. If an individual may have a latent tuberculosis infection, as defined in A.A.C. R9-6-1201: ii. Annually obtaining documentation of the individual's freedom from symptoms of infectious tuberculosis, signed by a medical practitioner, occupation health provider, as defined in A.A.C. R9-6-801, or local health agency, as defined in A.A.C. R9-6-101. 1. A review of the CDC website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used." 2. A review of E3's (hired in 2024) personnel record revealed E3 was hired as the program manager and behavioral health technician (BHT). E3's personnel record revealed documentation of freedom from symptoms of infectious TB, signed by a medical practitioner (dated in June 2022). However, current documentation of freedom from symptoms of infectious TB was not available for review. 3. In an interview, E3 acknowledged current documentation of E3's freedom from symptoms of infectious TB was not available for review. 4. A review of E5's (hired in 2024) personnel record revealed E5 was hired as a BHT. E5's personnel record revealed documentation of the individual's freedom from infectious TB. However, documentation of the individual's freedom from infectious TB, per R9-10-113(A)(2)(a)(iii) of two-step testing, was not available for review. 5. In an interview, E3 acknowledged documentation of E5's freedom from infectious TB, per R9-10-113(A)(2)(a)(iii) of two-step testing, was not available for review. 6. A review of E6's (hired in 2024) personnel record revealed E6 was hired as a BHT. E6's personnel record revealed documentation of the individual's freedom from infectious TB. However, documentation of the individual's freedom from infectious TB, per R9-10-113(A)(2)(a)(iii) of two-step testing, was not available for review. 7. In an interview, E3 acknowledged documentation of E6's freedom from infectious TB, per R9-10-113(A)(2)(a)(iii) of two-step testing, was not available for review. This Rule was cited during the compliance and complaint inspection conducted on February 7, 2024. A letter, dated March 1, 2024, stated "Enclosed is a copy of the Statement of Deficiencies (SOD), which describes the violations the Department found at the facility. Because the case has been referred to the Enforcement Team, the Department is not requesting a WRITTEN Plan of Correction (POC) at this time. However, the Department still requires that you make corrections to all violations noted in the SOD."