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

raw_content: The following deficiencies were found during the compliance inspection and investigation of complaint AZ00206058 conducted on February 7, 2024:

findings: 1. The Compliance Officer requested, on February 7, 2024 at 9:48AM, to review the following documentation: -E2's complete personnel record to include documentation of A.R.S. \'a7 36-425.03(E); -E6's and E7's complete personnel records to include documentation of evidence of freedom from infectious tuberculosis, as specified in R9-10-113; verification of skills and knowledge; completed orientation; in-service education; compliance with A.R.S. \'a7 36-425.03(E)(G); -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; and -R1's, R3's, and R4's complete medical records to include documentation of a medical history and physical examination or nursing assessment (per R9-10-707(A)(6)). However, the aforementioned documentation was not provided for review within two hours after a Department request. 2. 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, record review, and interview, the administrator failed to ensure if a resident's absence was unauthorized, the resident's parent or legal guardian was notified within an hour after determining the resident's absence was unauthorized. The deficient practice posed a risk as the residents were minors.

findings: 1. A review of documentation revealed a complaint was received by the Department on February 6, 2024. The complaint alleged a resident (later identified as R2) had an unauthorized absence and later passed away. 2. A review of facility documentation revealed a policy and procedure titled "Entering & Exiting Premises; AWOL/AMA policy" (dated August 1, 2023). The policy and procedure stated " ... A resident's absence is considered AWOL or AMA, (Against Medical Advice) when found absent from the premise for over 1 hour." 3. A review of facility documentation revealed a document titled "Arizona Health Care Cost Containment System INCIDENT, ACCIDENT OR DEATH REPORT" (dated February 4, 2024). The document stated "Date of Incident 02/03/2024 ... Time of Incident 08:00 PM ... Immediately [sic] [R2, R3, and R4] ran to their rooms picked up back packs and ran out of the door. The administrator of Basami House was contacted by the staff member, and the police was [sic] contacted immediately incase [sic] the fight got out of control." 4. A review of R2's medical record revealed a progress note (dated February 3, 2024 at 8:20PM). The progress note stated "Resident was fighting peers ... [R2] then took off." 5. A review of R3's medical record revealed a progress note (dated February 3, 2024 at 8:00PM). The progress note stated "Resident was fighting peer when staff called the police [R3] then took off." 6. A review of R4's medical record revealed a progress note (dated February 3, 2024 at 8:30PM). The progress note stated "Resident was fighting peers after that [R4] took off." 7. A review of facility documentation revealed an email (dated February 3, 2024 at 10:03PM) was sent from E1 to R2's parent or legal guardian. The email stated "[R2] and two other [residents] ganged up fought another [resident] and afterwards they ran away." 8. A review of facility documentation revealed a text message (dated February 3, 2024 at 9:46PM) from E1 to R3's parent or legal guardian. The text message stated "[R3] fought another [resident] then ran away." 9. A review of facility documentation revealed a text message (dated February 3, 2024 at 9:46PM) from E1 to R4's parent or legal guardian. The text message stated "[R4] ran away at 8:00 am [sic] after fighting another resident." 10. In an interview, E1 acknowledged the resident's parents or legal guardians were not notified within an hour after determining the resident's absences were unauthorized.

evidence: Based on documentation review, record review, and interview, the administrator failed to maintain a log of unauthorized absences for at least 12 months after the date of a resident's absence to include the name of a resident absent without authorization, name of the individual to whom the report required in subsection (K)(7) was submitted, and the date of the report. The deficient practice posed a risk if this information was required to be reviewed under R9-10-704.

findings: 1. A review of documentation revealed a complaint was received by the Department on February 6, 2024. The complaint alleged a resident (later identified as R2) had an unauthorized absence and later passed away. 2. A review of facility documentation revealed a document titled "Arizona Health Care Cost Containment System INCIDENT, ACCIDENT OR DEATH REPORT" (dated February 4, 2024). The document stated "Date of Incident 02/03/2024 ... Time of Incident 08:00 PM ... Immediately [sic] [R2, R3, and R4] ran to their rooms picked up back packs and ran out of the door. The administrator of Basami House was contacted by the staff member, and the police was [sic] contacted immediately incase [sic] the fight got out of control." 3. A review of R2's medical record revealed a progress note (dated February 3, 2024 at 8:20PM). The progress note stated "Resident was fighting peers ... [R2] then took off." 4. A review of R3's medical record revealed a progress note (dated February 3, 2024 at 8:00PM). The progress note stated "Resident was fighting peer when staff called the police [R2] then took off." 5. A review of R4's medical record revealed a progress note (dated February 3, 2024 at 8:30PM). The progress note stated "Resident was fighting peers after that [R4] took off." 6. A review of facility documentation revealed an email (dated February 3, 2024 at 10:03PM) was sent from E1 to R2's parent or legal guardian. The email stated "[R2] and two other [residents] ganged up fought another [resident] and afterwards they ran away." 7. A review of facility documentation revealed a text message (dated February 3, 2024 at 9:46PM) from E1 to R3's parent or legal guardian. The text message stated "[R3] fought another [resident] then ran away." 8. A review of facility documentation revealed a text message (dated February 3, 2024 at 9:46PM) from E1 to R4's parent or legal guardian. The text message stated "[R4] ran away at 8:00 am [sic] after fighting another resident." 9. The Compliance Officer requested to review the facility's written log of unauthorized absences. However, a written log of unauthorized absences was not provided for review. 10. In an interview, E1 reported a written log of unauthorized absences was not available for review. 11. In an interview, the findings were reviewed with E1 and no additional comments or statements were provided regarding the findings.

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel member's skills and knowledge were verified and documented before the personnel member provided behavioral health services, for two of five behavioral health technicians (BHTs) sampled. The deficient practice posed a risk to the health and safety of residents if a personnel member was not qualified to provide behavioral health services.

findings: 1. A review of facility documentation revealed a policy and procedure titled "Medication Services: Assistance in the Self-administration of Medication" (dated August 1, 2023). The policy and procedure stated " ... 4. Under the supervision and training of the Registered Nurse, BHTs (behavioral health technicians) and Behavioral Health Paraprofessionals (BHPPs) shall provide support to a resident during the assistance in the self-administration of medication process" and "... BHRF's Nurse Practitioner of Registered Nurse is responsible for verifying all personnel members' skills and knowledge prior to providing assistance in the self-administration of medication to a resident. Each personnel shall demonstrate hands-on, their skills and knowledge of assistance in the self-administration of medication before providing services to residents." 2. A review of E6's (hired in 2024) and E7's (hired in 2024) personnel records revealed E6 and E7 were hired as BHTs. However, documentation of the verification of E6's and E7's skills and knowledge in assistance in the self-administration of medication before E6 and E7 provided behavioral health services was not available for review. 3. A review of R1's medical record revealed medication administration records (MARs) for January 2024 and February 2024 The MARs revealed E6 (February 2024) and E7 (January 2024 and February 2024) provided assistance in the self-administration of medication to R1. 4. A review of R2's medical record revealed a MAR for February 2024. The MAR revealed E7 provided assistance in the self-administration of medication to R2. 5. A review of R3's medical record revealed a MAR for January 2024. The MAR revealed E7 provided assistance in the self-administration of medication to R3. 6. A review of R4's medical record revealed a MAR for February 2024. The MAR revealed E7 provided assistance in the self-administration of medication to R4. 7. In an interview, E1 reported E6's and E7's skills and knowledge were verified and E1 acknowledged the documentation was not available for review.

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel member completed orientation before providing behavioral health services, for one of eight personnel members sampled. The deficient practice posed a risk if E2 was unable to meet resident's needs.

findings: R9-10-101.155. "Orientation" means the initial instruction and information provided to an individual before the individual starts work or volunteer services in a health care institution. 1. A review of facility documentation revealed a policy 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 E2's (hired in 2024) personnel record revealed E2 was hired as the behavioral health professional (BHP). However, documentation of E2's completed orientation was not available for review. 3. A review of R1's, R2's, and R4's medical records revealed behavioral health assessments and treatment plans completed by E2. 4. In an interview, E1 reported E2 had not completed orientation. 5. In an interview, the findings were reviewed with E1 and no additional comments or statements were provided regarding the findings

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 three of eight personnel members sampled.

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 E6's (hired in 2024) and E7's (hired in 2024) personnel records revealed E6 and E7 were hired as behavioral health technicians. However, E6's and E7's personnel records revealed documentation a completed orientation was not available for review. 3. In an interview, E1 reported E6 and E7 had completed orientation, and E1 acknowledged the documentation was not available for review. 4. In an interview, E1 acknowledged a personnel record was not maintained for each personnel member to include documentation of the individual's completed orientation. 5. A review of facility documentation revealed a policy and procedure titled "Medication Services: Assistance in the Self-administration of Medication" (dated August 1, 2023). The policy and procedure stated " ... 4. Under the supervision and training of the Registered Nurse, BHTs (behavioral health technicians) and Behavioral Health Paraprofessionals (BHPPs) shall provide support to a resident during the assistance in the self-administration of medication process ... BHRF's Nurse Practitioner of Registered Nurse is responsible for verifying all personnel members' skills and knowledge prior to providing assistance in the self-administration of medication to a resident. Each personnel shall demonstrate hands-on, their skills and knowledge of assistance in the self-administration of medication before providing services to residents." 6. A review of E6's and E7's personnel records revealed documentation of training in assistance in the self-administration of medication was not available for review. 7. In an interview, E1 reported E6 and E7 had completed training in assistance in the self-administration of medication, and E1 acknowledged the documentation was not available for review. 8. 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." 9. A review of E2's (hired in 2024) personnel record revealed E2 was hired as the behavioral health professional. However, E2's personnel record revealed documentation of initial training in fall prevention and fall recovery was not available for review. 10. In an interview, E1 reported E2 completed initial training in fall prevention and fall recovery but this documentation was not available for review. 11. A review of E6's and E7's personnel records revealed documentation of initial training training in fall prevention and fall recovery was not available for review. 12. In an interview, E1 reported E6 and E7 completed initial training in fall prevention and fall recovery, and E1 acknowledged the documentation was not available for review. 13. In an interview, E1 acknowledged a personnel record was not maintained for each personnel member to include documentation of the individual's completed orientation and in-service education.

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 three of seven personnel members sampled. The deficient practice posed a risk if E2, E6 and E7 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. In an interview, E1 reported E2 had documentation of compliance with A.R.S. \'a7 36-425.03(E). E1 reported E2 was supposed to send this documentation to E1. 3. A review of E6's (hired in 2024) and E7's (hired in 2024) personnel record revealed E6 and E7 were hired as behavioral health technicians. E6's and E7's personnel records revealed valid fingerprint clearance cards. However, documentation of compliance with A.R.S. \'a7 36-425.03(E)(G) was not available for review. 4. In an interview, E1 reported E6 and E7 had documentation of compliance with A.R.S. \'a7 36-425.03(E)(G), and E1 acknowledged the documentation was not available for review.

findings: 1. A review of facility documentation revealed daily staffing schedules for January 2024 and February 2024 were not available for review. 2. A review of facility documentation revealed a daily staffing schedule dated for August 1-13, 2023. 3. A review of R1's, R2's, R3's, and R4's medical records revealed R1, R2, R3, and R4 were admitted in 2024. 4. In an interview, E1 reported daily staffing schedules for January 2024 and February 2024 were not developed. 5. In an interview, E1 later reported a daily staffing schedule for February 2024 may have been developed, and E1 acknowledged theis schedule was not available for review. 6. In an interview, E1 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 January 2024 and February 2024 were not available for review.

evidence: Based on record review and interview, the administrator failed to ensure general consent was obtained from a resident's representative, if the resident was not an adult, for one of four residents sampled. The deficient practice posed a risk if the resident's representative did not consent to treatment.

findings: R9-10-101.98."General consent" means documentation of an agreement from an individual or the individual's representative to receive ... behavioral health services to address the individual's behavioral health issues. 1. A review of R2's (admitted in 2024) medical record revealed documentation of general consent obtained from R2's representative was not available for review. 2. In an interview, E1 acknowledged general consent was not obtained from a resident's representative, if the resident was not an adult.

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 four 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: R9-10-101(24) "Assistance in the self-administration of medication" means restricting a patient's access to the patient's medication and providing support to the patient while the patient takes the medication to ensure that the medication is taken as ordered. 1. A review of facility documentation revealed a scope of services (dated August 1, 2023). The scope of services stated "... 4. Medication Services: Assistance in the self-administration of medication." 2. A review of R1's (admitted in 2024), R2's (admitted in 2024), R3's (admitted in 2024), and R4's (admitted in 2024) medical records revealed treatment plans (dated in 2024). However, R1's, R2's, R3's, and R4's treatment plans did not include whether assistance in the self-administration of medication was to be provided to R1, R2, R3, and R4. 3. A review of R1's medical record revealed a medication administration record (MAR) for February 2024. The MAR documented R1 received medication services on February 1-5, 2024. 4. A review of R2's medical record revealed a MAR for February 2024. The MAR documented R2 received medication services on February 1-3, 2024. 5. A review of R3's medical record revealed a MAR for February 2024. The MAR documented R2 received medication services on February 3, 2024. 6. A review of R4's medical record revealed a MAR for February 2024. The MAR documented R4 received medication services on February 1-3, 2024. 7. In an interview, E1 acknowledged R1's, R2's, R3's, and R4's treatment plans did not include the behavioral health services to be provided to the residents.

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 three of four residents sampled.

findings: 1. A review of R2's (admitted in 2024), R3's (admitted in 2024), and R4's (admitted in 2024) medical records revealed treatment plans (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, E1 reported E1 tried to get R1's treatment plan signed by the resident's representative. 3. In an interview, E1 reported R3's treatment plan was signed. However, documentation to demonstrate R3's treatment plan was signed was not available for review. 4. In an interview, E1 acknowledged R2's, R3's, and R4's treatment plans did not include the signature of the resident's representative and date signed, or documentation of the refusal to sign.

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

findings: R9-10-101(24) "Assistance in the self-administration of medication" means restricting a patient's access to the patient's medication and providing support to the patient while the patient takes the medication to ensure that the medication is taken as ordered. 1. A review of facility documentation revealed a scope of services (dated August 1, 2023). The scope of services stated "... 4. Medication Services: Assistance in the self-administration of medication." 2. A review of R1's medical record revealed a medication administration record (MAR) for February 2024. The MAR documented R1 received medication services on the following dates: -"Clonidine HCL 0.2mg:" February 1-4, 2024; and -"Risperidone 0.5mg:" February 1-5, 2024. However, medication orders for the aforementioned medications were not available for review. 3. A review of R1's medical record revealed a medication list (dated January 26, 2024). The medication list stated the following: -"Clonidine HCl 0.2 MG ... one tablet daily;" and -"Risperidone 0.5 MG ... one tablet two times a day." However, the medication list was not authenticated by a medical practitioner. 4. In an interview, E1 reported R1's medication list was what R1's clinic provided as medication orders. 5. A review of R3's medical record revealed a MAR for January 2024 and February 2024. The MAR documented R3 received medication services on the following date: -"Olanzapine 5mg:" January 22-31, 2024; and February 3, 2024. However, a medication order for the aforementioned medication was not available for review. 6. A review of R3's medical record revealed a medication list (dated January 22, 2024). The medication list stated the following: -"Olanzapine ... Take 5mg by mouth once in p.m." However, the medication list was not authenticated by a medical practitioner. 7. In an interview, E1 acknowledged signed medication orders for R1's and R3's aforementioned medications were not available for review.

evidence: Based on record review and interview, the administrator failed to ensure a resident's medical record contained an assessment, for three of four medical records 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 2024), R3's (admitted in 2024), and R4's (admitted in 2024) medical records revealed a medical history and physical examination or nursing assessment (per R9-10-707(A)(6)) was not available for review. 2. In an interview, E1 reported a nursing assessment was performed on R1, R3, and R4 upon admission by E1, and reported E1 was unable to locate the assessments. 3. In an interview, E1 acknowledged R1's, R3's, and R4's medical records did not contain a medical history and physical examination or nursing assessment (per R9-10-707(A)(6)).

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

findings: R9-10-101(24) "Assistance in the self-administration of medication" means restricting a patient's access to the patient's medication and providing support to the patient while the patient takes the medication to ensure that the medication is taken as ordered. 1. A review of facility documentation revealed a scope of services (dated August 1, 2023). The scope of services stated "... 4. Medication Services: Assistance in the self-administration of medication." 2. A review of R1's medical record revealed a medication administration record (MAR) for February 2024. The MAR documented R1 received medication services on the following dates: -"Clonidine HCL 0.2mg:" February 1-4, 2024; and -"Risperidone 0.5mg:" February 1-5, 2024. However, medication orders for the aforementioned medications were not available for review. 3. A review of R1's medical record revealed a medication list (dated January 26, 2024). The medication list stated the following: -"Clonidine HCl 0.2 MG ... one tablet daily;" and -"Risperidone 0.5 MG ... one tablet two times a day." However, the medication list was not authenticated by a medical practitioner. 4. In an interview, E1 reported R1's medication list was what R1's clinic provided. 5. A review of R3's medical record revealed a MAR for January 2024 and February 2024. The MAR documented R3 received medication services on the following date: -"Olanzapine 5mg:" January 22-31, 2024; and February 3, 2024. However, a medication order for the aforementioned medication was not available for review. 6. A review of R3's medical record revealed a medication list (dated January 22, 2024). The medication list stated the following: -"Olanzapine ... Take 5mg by mouth once in p.m." However, the medication list was not authenticated by a medical practitioner. 7. In an interview, E1 acknowledged assistance in the self-administration of medication provided to R1 and R3 was not in compliance with an order.

evidence: Based on observation, record review, and interview, the administrator failed to ensure the premises and equipment were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a risk as R1's, R2's, R3's, and R4's treatment plans did not allow for R1, R2, R3, and R4 to be around non-shatter-proof mirrors.

findings: 1. The Compliance Officer observed an unoccupied master bedroom with four beds. The Compliance Officer observed a bathroom located 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. The Compliance Officer observed a common bathroom in a hallway. The Compliance Officer observed resident bedrooms in the same hallway. 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. 3. A review of R1's (admitted in 2024) medical record revealed a treatment plan (dated in 2024). However, documentation to indicate R1 was allowed to have access to non-shatter-proof mirrors was not available for review. 4. A review of R2's (admitted in 2024) medical record revealed a treatment plan (dated in 2024). The treatment plan stated " ... Has a history of hospitalizations for self-harm behavior." However, documentation to indicate R2 was allowed to have access to non-shatter-proof mirrors was not available for review. 5. A review of R3's medical record revealed a behavioral health assessment (dated in 2024). The assessment stated " ... [R3] has attempted suicide in the past and participated in self-harm via cutting." 6. A review of R3's medical record revealed a treatment plan (dated in 2024). However, documentation to indicate R3 was allowed to have access to non-shatter-proof mirrors was not available for review. 7. A review of R4's (admitted in 2024) medical record revealed a treatment plan (dated in 2024). The treatment plan stated " ... Personal history of suicidal behavior." However, documentation to indicate R4 was allowed to have access to non-shatter-proof mirrors was not available for review. 8. In an interview, E1 acknowledged the premises and equipment were not free from a condition or situation that may cause a resident or other individual to suffer physical injury.

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;

findings: 1. The Compliance Officer observed an unoccupied master bedroom with four beds. The Compliance Officer observed a bathroom located 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 2024) medical record revealed a treatment plan (dated in 2024). However, documentation to indicate R1 was allowed to have access to non-shatter-proof mirrors was not available for review. 3. A review of R2's (admitted in 2024) medical record revealed a treatment plan (dated in 2024). The treatment plan stated " ... Has a history of hospitalizations for self-harm behavior." However, documentation to indicate R2 was allowed to have access to non-shatter-proof mirrors was not available for review. 4. A review of R3's medical record revealed a behavioral health assessment (dated in 2024). The assessment stated " ... [R3] has attempted suicide in the past and participated in self-harm via cutting." 5. A review of R3's medical record revealed a treatment plan (dated in 2024). However, documentation to indicate R3 was allowed to have access to non-shatter-proof mirrors was not available for review. 6. A review of R4's (admitted in 2024) medical record revealed a treatment plan (dated in 2024). The treatment plan stated " ... Personal history of suicidal behavior." However, documentation to indicate R4 was allowed to have access to non-shatter-proof mirrors was not available for review. 7. 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 consisting of assessing risks of prior exposure to infectious TB, determining if the individual had signs or symptoms of TB, and the individual's freedom from infectious TB, for four of eight personnel members sampled and for two of four 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 E2's (hired in 2024) personnel record revealed E2 was hired as the behavioral health professional. E2's personnel record revealed documentation of the individual's freedom from infectious TB. However, documentation of the baseline screening, per R9-10-113(A)(2)(a)(iii) of two-step testing, was not available for review. 3. In an interview, the findings were reviewed with E1 and no additional comments or statements were provided regarding the findings. 4. A review of E6's (hired in 2024) personnel record revealed E6 was hired as a behavioral health technician (BHT). However, documentation of baseline screening consisting of assessing risks of prior exposure to infectious TB, determining if the individual had signs or symptoms of TB, and 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, E1 reported E6 had documentation of baseline screening consisting of assessing risks of prior exposure to infectious TB, determining if the individual had signs or symptoms of TB, and the individual's freedom from infectious TB, per R9-10-113(A)(2)(a)(iii) of two-step testing, but this documentation was not available for review. 6. A review of E7's (hired in 2024) personnel record revealed E7 was hired as a BHT. However, documentation of baseline screening consisting of assessing risks of prior exposure to infectious TB, determining if the individual had signs or symptoms of TB, and the individual's freedom from infectious TB was not available for review. 7. In an interview, E1 reported E7 had documentation of baseline screening consisting of assessing risks of prior exposure to infectious TB, determining if the individual had signs or symptoms of TB, and the individual's freedom from infectious TB but this documentation was not available for review. 8. A review of E8's (hired in 2024) personnel record revealed E8 was hired as a BHT. However, documentation of baseline screening consisting 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. 9. A review of R1's (admitted in 2024) medical record revealed documentation of baseline screening consisting of determining if the individual had signs or symptoms of TB was not available for review. 10. A review of R3's (admitted in 2024) medical record revealed documentation of baseline screening consisting of assessing risks of prior exposure to infectious TB, determining if the individual had signs or symptoms of TB, and the individual's freedom from infectious TB was not available for review. 11. In an interview, the findings were reviewed with E1 and no additional comments or statements were provided regarding the findings.


state: AZ

facility_name: BASAMI HOUSE, LLC

summary: Initial Monitoring - 11/27/2023

raw_content: No deficiencies were found during the on-site abbreviated follow-up inspection conducted on November 27, 2023.

inspection_type: Initial Monitoring


summary: Compliance (Initial) - 8/1/2023 - 8/15/2023

raw_content: No deficiencies were found during the on-site initial inspection conducted on August 1, 2023, and the off-site documentation review completed on August 15, 2023.

inspection_type: Compliance (Initial)


facility_name: PTL BEHAVIORAL HEALTH, LLC

summary: Complaint;Compliance (Annual) - 3/25/2025

raw_content: An on-site investigation of complaint AZ00107214 was conducted on March 25, 2025, and no deficiencies were cited.

inspection_type: Complaint;Compliance (Annual)


summary: Change of Service - 3/25/2025

inspection_type: Change of Service


summary: Compliance (Annual) - 6/25/2024

raw_content: The following deficiency was found during the attempted on-site compliance on June 25, 2024:

inspection_type: Compliance (Annual)

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 health and safety risk as the Department was unable to determine substantial compliance.

findings: 1. A review of Department documentation revealed the facility's perpetual license was effective on July 26, 2023. 2. The Compliance Officers arrived at the facility on June 25, 2024, at 9:45 a.m. to conduct a compliance inspection. The Compliance Officer rang the doorbell and knocked on the front door, however, there was no response. The Compliance Officer attempted to contact the facility by telephone at 9:50 am. There were no answers to the facility contact telephone numbers with a message left providing the Compliance Officers cell phone contact number. An email was sent by the Department at 9:56 a.m. identifying the Departments attempt to contact the facility to conduct an inspection and requesting an immediate returned response to the Compliance Officer. 3. The department received a phone call from E1 at 10:05 am asking to speak with the Compliance Officer. The Compliance Officer returned the call with E1 reporting E1 No one would be able to come to facility as E1 was about 45 minutes away and was sick and the designee was at home with a sick child. However, the facility does not currently have residents living on site. E1 acknowledged the administrator failed to provide complete acquiescence in any entry or inspection of the premises during the term of the license.


summary: Initial Monitoring - 11/13/2023

raw_content: The following deficiencies were found during the on-site abbreviated follow-up inspection conducted on November 13, 2023:

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

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of the individual's completed in-service education as required by policies and procedures, for six of six personnel members sampled.

findings: R9-10-101.115. "In-service education" means organized instruction or information that is related to physical health services or behavioral health services and that is provided to a medical staff member, personnel member, employee, or volunteer. 1. A review of facility documentation revealed an undated policy and procedure titled "FALL PREVENTION AND FALL RECOVERY." The policy and procedure stated " ...PTL Behavioral Health LLC personnel will be required to complete a Fall Prevention and Fall Recovery training within their first 30 days of hire ..." 2. A review of E1's, E2's, E3's, and E4's personnel records revealed training documents titled "FALLS PREVENTION MEASURES." However, the training documents did not include fall recovery. 3. A review of E5's and E6's personnel records revealed initial training in fall prevention and fall recovery was not available for review. 4. In an interview, E1 acknowledged personnel records did not include documentation of the individual's completed in-service education as required.

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

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

findings: R9-10-113.A.2.c. 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: c. Annually providing training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed by or providing volunteer services for the health care institution; 1. A review of facility documentation revealed an undated document. The document contained compliance with R9-10-113.A.2.a.b.d.e. However, the document revealed non-compliance with R9-10-113.A.2.c. 3. In an interview, E1 acknowledged the facility had not established and documented TB infection control activities as specified in R9-10-113.A.2.c.


summary: Compliance (Initial) - 5/23/2023 - 7/26/2023

raw_content: No deficiencies were found during the on-site initial inspection conducted on May 23, 2023, and the off-site documentation review completed on July 26, 2023.


facility_name: SRC DESERT COVE

summary: Other - 6/28/2024 - 7/26/2024

raw_content: No deficiencies were found during the on-site inspection to modify the population from adults to children conducted on June 28, 2024:

inspection_type: Other


summary: Initial Monitoring - 12/6/2023

raw_content: No deficiencies were found during the on-site abbreviated follow-up inspection conducted on December 6, 2023.


summary: Compliance (Initial) - 7/5/2023

raw_content: No deficiencies were found during the on-site initial inspection conducted on July 5, 2023.


facility_name: HUMAN CARE SERVICE II

summary: Complaint;Compliance (Annual) - 3/12/2026

raw_content: The following deficiencies were found during the on-site compliance inspection and investigation of complaints 00161675 and 00161677 conducted on March 12, 2026.

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

evidence: Based on record review and interview, the health care institution's chief administrative officer failed to ensure each individual who is employed by the health care institution, or is admitted to the healthcare institution had an assessment of risks of prior exposure to infectious tuberculosis (TB), determining if the individual had signs or symptoms of tuberculosis, or obtained documentation of the individual’s freedom from infectious tuberculosis for three of seven records sampled. The deficient practice posed a health and safety risk if a personnel member or resident was not free from infectious TB.

findings: 1. A review of R2’s medical record revealed a document from “My Dr. Now” titled “After Visit Summary”, dated 02/01/2026. The document states “…You saw Lisa Wakefield, NP on Sunday February 1, 2026. The following issues were addressed…Encounter for tuberculin skin test…” 2. A review of E3 and E5's personnel records revealed no documentation of a TB risk assessment or signs and symptoms of TB. 3. A review of facility policies and procedures revealed a policy titled “Tuberculosis Mandate”. The policy states “…Prior to a resident being admitted to the facility [sic] must have written documentation he or she has received a TB skin test…Each staff will need to complete a baseline screening form when having a TB done…” 4. In an interview, E1 reported being unaware of the missing TB records. 5. In an exit interview, the findings were reviewed with E1. No additional comments, statements, or documentation were provided regarding the findings.

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

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

findings: A.R.S. § 8-804(K) states "Before being employed in a position that provides direct services to children or vulnerable adults pursuant to subsection B, paragraphs 4, 5 and 10 and 11 or subsections C and D and E of this section, employees shall certify, under penalty of perjury, on forms that are provided by the department whether an allegation of abuse or neglect was made against them and was substantiated. The forms are confidential. If this certification does not indicate a current investigation or a substantiated report of abuse or neglect, the employee may provide direct services pending the findings of the central registry check." 1. A review of E5's personnel record revealed no documentation demonstrating the licensee submitted to the Department of Child Safety (DCS) in a manner prescribed by DCS, information necessary to conduct a central registry background check on E5. 2. In an interview, E1 reported being unaware of the missing central registry background check for E5. 3. In an exit interview, the findings were reviewed with E1. 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 was conducted on each shift at least once every three months and documented. The deficient practice posed a safety risk if employees were unable to implement a disaster plan.

findings: 1. In a review of the facilities documentation, no documentation was provided that the disaster drills were completed on any shift. 2. A review of facility documentation revealed a document titled “March Schedule”. The document shows the facility operates on two 12-hour shifts. 3. In an interview, E1 reported the facility operates on two 12-hour shifts. E1 reported the facility combines disaster drills with evacuation drills; however, no disaster drill documentation was available for review. 4. In an exit interview, the findings were reviewed with E1. No additional comments, statements, or documentation were provided regarding the findings.

rule: R9-10-720.B.5. Emergency and Safety Standards B. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 5. An evacuation drill for employees and residents on the premises is conducted at least once every six months on each shift;

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

findings: 1. A review of facility documentation revealed a document titled “March Schedule”. The document shows the facility operates on two 12-hour shifts, 8:00 to 8:00. 2. A review of facility documentation revealed documents titled "Human Care Services Fire drills are to be conducted every three [SIC] on each shift”. The documents were dated: January 20, 2025, at 3:30 pm, April 14, 2025, at 7:00 pm, August 6, 2025, at 12:13 pm, October 30, 2025, at 2:09 pm, and January 12, 2026, at 7:05 pm. The Compliance Officer observed no additional documentation of evacuation drills conducted at least once every six months on each shift was available for review. 3. In an interview, E1 reported the facility operates on two 12-hour shifts. E1 reported no other evacuation drills were available for review. 4. In an exit interview, the findings were reviewed with E1. No additional comments, statements, or documentation were provided regarding the findings.

rule: R9-10-720.C.1. Emergency and Safety Standards 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 documentation review and interview, the administrator failed to obtain a fire inspection conducted according to the time-frame established by the local fire department or the State Fire Marshal. The deficient practice posed a potential risk to the health and safety of a resident or other individual in the event of a fire if hazards had not been identified, corrected, and standards expected of the facility were not followed.

findings: 1. A review of facility documentation revealed a document titled “Group Home – Fire Inspection (1-6)”, dated 10/14.2024. The document stated “…Payment Received. Ready to Request Inspection…Issued 10/14/2024…” and "Describe the purpose of the project, annual fire." No other fire inspection documentation was available for review. 2. In an interview, E1 reported the facility had not received a fire inspection since October 14, 2024. E1 reported being unaware if the inspection is required annually. 3. In a telephonic interview, O1 with the Maricopa Fire Department reported fire inspections for residential facilities are valid for one year. 4. In an exit interview, the findings were reviewed with E1. No additional comments, statements, or documentation were provided regarding the findings.

rule: R9-10-722.B.8.c. Physical Plant Standards B. An administrator shall ensure that: 8. A resident bedroom complies with the following: c. Contains a door that opens into a hallway, common area, or outdoors;

evidence: Based on observation and interview, the administrator failed to ensure a resident's bedroom contained a door. The deficient practice posed a safety risk if residents were unable to ensure their privacy.

findings: 1. During an environmental tour, the Compliance Officer observed an occupied resident bedroom with a door unattached from the door frame. 2. In an interview, E1 reported the bedroom door was removed during an incident and would be remounted immediately. 3. In an exit interview, the findings were reviewed with E1. No additional comments, statements, or documentation were provided regarding the findings.


summary: Complaint - 2/5/2026

raw_content: An on-site investigation of complaint 00158044 was conducted on February 5, 2026, and the following deficiencies were cited:

inspection_type: Complaint

rule: R9-10-703.K.7.a-b. Administration 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 b. For a resident who is under a court's jurisdiction, the appropriate court;

evidence: Based on record review, documentation review, and interview, the administrator failed to ensure that if a resident's absence was unauthorized, within an hour after determining that the resident's absence was unauthorized, notified the resident's parent or legal guardian for a resident who was under 18 years of age. The deficient practice posed a risk as the parents or guardians received delayed notification of a minor's absence from the facility.

findings: 1. A review of R1's and R3's medical records revealed incident reports dated February 2, 2026. The incident reports revealed that minors R1 and R3 were absent without leave from the facility. R1 and R3 were located by the Maricopa County Sheriff's Department and returned to the facility. The incident report revealed no documentation of coordination or communication with R1's or R3's family. 2. A review of the facility policies and procedures revealed a policy titled "Resident AWOL from the facility." The policy stated "...To ensure the safety of all residents being served at the facility....It is the policy of Human Care Services Home Care that when a resident is absent from the facility without permission, the following protocol shall be implemented: c. Staff will notify the residents represenative, guardian, or court if they have any, depending on the severity of AWOL. f.) Staff will be responsible for coordinating and communicating with family members and local authorities...." 3. In an interview, E1 reported that the identified incident did not include communication with R1's and R3's representatives. E1 reported that the incidents did include communication with R1's and R3's case management team and the police department. E1 acknowledged that R1's and R3's medical records failed to include notifying the guardian or representative of R1's and R3's absence from the facility.

rule: R9-10-706.H.1.a. Personnel H. An administrator shall ensure that personnel records are: 1. Maintained: a. Throughout an individual's period of providing services in or for the behavioral health residential facility, and

evidence: Based on observation, record review, and interview, the administrator failed to ensure personnel records were maintained throughout an individual's period of providing services in or for the behavioral health residential facility. The deficient practice posed a risk as the Department can not determine compliance with the personnel providing services.

findings: 1. The Compliance Officer observed E4 working at the time of the inspection as a Behavioral Health Technician. 2. The Compliance Officer requested to review the personnel record for E4 at 9:46 AM. However, the Compliance Officer was not provided the complete personnel record to review during the inspection. 3. In an interview, E4 reported working at the facility as a Behavioral Health Technician. E4 provided the Compliance Officer a copy of E4's fingerprint clearance card, cardiopulmonary resuscitation card, and first aid card from E4's personal email. E4 reported having received orientation, skills, and knowledge verification and had completed the required training. 4. In an interview, E1 reported E4 had a personnel record that had been reviewed by the Department in the past; however, at the time of the inspection, the personnel record was not provided to the Compliance Officer as it was at another facility. E1 acknowledged E1 did not maintain E4's personnel file for the Department to review at the time of the inspection.


summary: Complaint - 11/6/2025

raw_content: The following deficiency was found during the on-site investigation of complaint 00148672 conducted on November 6, 2025.

rule: R9-10-716.A.7.b. Behavioral Health Services A. An administrator shall ensure that: 7. A resident does not: b. Share any space, participate in any activity or treatment, or verbally or physically interact with any other resident that may present a threat to the resident's health or safety, based on the other resident's documented diagnosis, treatment needs, developmental levels, social skills, verbal skills, and personal history.

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a resident does not share any space, participate in any activity or treatment, or verbally or physically interact with any other resident that may present a threat to the resident's health or safety, based on the other resident's documented diagnosis, treatment needs, developmental levels, social skills, verbal skills, and personal history. The deficient practice posed a risk as the health and safety of residents with a history of physical aggression and assault was elevated and compromised.

findings: 1. A review of facility documentation revealed a document titled "Incident, Accident, or Death Report, " dated August 2025. The document stated, “Description of the Incident:..While on shift, E2 observed R3, R2, and R4 making verbal statements about their intent to physically harm peer R1. E2 immediately intervened, providing verbal redirection and reinforcing expectations for safe and respectful behavior. Despite staff engagement, R3, and R2 became verbally aggressive, making additional threats toward R1. As E2 continued to redirect and de-escalate, R3, and R2 suddenly ran toward the restroom where R1 was taking a shower. E2 moved to block the restroom entry, positioning themselves between the aggressors and R1, and issued clear verbal directives to stop. R3, and R2 attempted to push past E2 in an effort to access R1. During this struggle, they were able to strike R1 before E2 successfully separated R1 and escorted R1 to the office for safety. Another E3 member remained in the common area to redirect and separate the other clients. Following the separation, R3, R2, and R4 made statements about destroying R1’s personal property. E2 firmly advised against any property damage; however, R2, and R3 entered R1’s room and began damaging R1’s belongings. E2 maintained a physical presence in the hallway, continued verbal redirection, and documented damages while working to de-escalate the group. At one point, R4 approached the office where R1 was located. E2 intercepted and attempted to redirect R1. R4 entered the office, began making a phone call without permission, placed R4 feet on the desk, and cursed at E2. E2 unplugged the phone to maintain program rules and prevent further escalation. R3, R2, and R4 continued with disruptive verbal aggression, including loud music played through personal mini-speakers. Despite ongoing redirection and processing from staff, the behavior persisted. For the safety of all residents and to prevent further escalation…” 2. A review of R2’s medical records revealed a document titled, “Minimum Elements of Behavioral Health Assessment,” dated June 2025. The document stated, “Diagnosis: ADHD combined type...Disruptive Mood Dysregulation Disorder...Unspecified Trauma and Stressor Related Disorder...Presenting Issues: R2 has spent time in detention center (Durango) for issues relating to fighting, property damage, and assault on a Peace Officer. R2 attended school but has been suspended for fighting. R2 also fought with peers at R2 previous placement…Risk assessment: … there is a history of aggression…Educational Status/History: …Missed a lot of school due to detention and fighting…Social History: R2 is said to be able to make friends but also has a history of fighting in school and at previous placements. R2 has assault charges on a Peace Officer. Easily influenced by peers… Legal Involvement (include custody/guardianship, COT, criminal justice history): Maricopa County charges for aggravated assault on a Peace Officer and Property Damage…” 3. A review of R2’s medical record revealed a document titled, “Treatment Plan,” dated June 2025. The document stated, “...CURRENT MEASURE: Aggravated assault on a Peace officer, fights in school, fights in placement, destruction of property…” 4. A review of R3’s medical record revealed a document titled, “Minimum Elements of Behavioral Health Assessment,” dated May 2025. The document stated, “Diagnosis: Unspecified mood [affective] disorder Continuing...Generalized Anxiety Disorder Continuing...Post-traumatic stress disorder Continuing...Child living in a group home...History of Presenting Issues: Per Report: R3 has a HX of self-harming behavior and negative behaviors in school and has negative interpersonal relationships with others…” 5. A review of R4’s medical record revealed a document titled, “Treatment Plan,” dated June 2025. The document stated, “CURRENT MEASURE: Physically/verbally aggressive when told no.” 6. A review of R4’s medical record revealed a document titled, “Minimal Elements of Behavioral Health Assessment,” dated June 2025. The document stated, “Diagnosis: Major Depressive Disorder, Single Episode, Unspecified... Unspecified Attention-Deficit/Hyperactivity Disorder...Parent-child relational problems... Presenting Issues: ...HCSI following a hospitalization relating to anger and aggression. R4 and R4’s parents had conflict over social media and R4 ended up pulling R4’s [parent] hair out. R4 feels R4’s parents treat R4 different than they do R4’s other siblings however parents indicate R4 struggles with the word “no”. Reports indicated R4 became physically aggressive with [parent], [sibling] and [sibling] after losing table privileges.” 7. In an interview, E1 reported R2, R3, and R4 have been discharged from the facility after the incident with R1. 8. In an exit interview, the findings were discussed with E1 and no additional comments or documentation were provided.


summary: Complaint - 10/15/2025

raw_content: The following deficiencies were found during the on-site investigation of complaints 00147584 and 00147781 conducted on October 15, 2025:

rule: R9-10-703.C.1.a. Administration 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 implement policies and procedures to cover job descriptions, duties, and qualifications, including required skills, knowledge, education, and experience for volunteers. The deficient practice posed a safety risk as policies and procedures reinforce and clarify standard expectations, and these standards were not implemented.

findings: 1. A review of the facility's policies and procedures revealed a document titled "Employees, Personnel, Volunteers Job requirements." The document stated, "...At this time HUMAN CARE SERVICES Home Care will not be utilizing volunteers or internship individuals. In the event the situation should warrant these individuals, we will develop our policies and procedures to address the policies and procedures that will apply to them...." 2. A review of the facility's policies and procedures revealed no evidence of documentation that covered job descriptions, duties, and qualifications, including required skills, knowledge, education, and experience for volunteers. 3.. A review of E2's personnel record revealed a document titled "Employment Application." The document stated E2 applied for the position of "Volunteer." 4. In an interview, E1 confirmed E2 was hired as a volunteer. E1 confirmed the facility did not have a policy and procedure established, documented, and implemented to protect the health and safety of a resident that covered job descriptions, duties, and qualifications, including required skills, knowledge, education, and experience of volunteers. 5. In an exit interview, the findings were discussed with E1 and no additional statements or documentation was provided.

rule: R9-10-703.C.2.d. Administration 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: d. Cover emergency safety responses;

evidence: Based on documentation review and interview, the administrator failed to ensure policies and procedures for behavioral health services and physical health services were implemented to protect the health and safety of a resident that covered emergency safety responses. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of personnel members and those standards were not complied with.

findings: 1. A review of the facility's policies and procedures revealed a document titled, "Behavioral Management of an Out-of-Control Resident." The document stated, "...III. Procedures:...n. Emergency Safety Response is not utilized at HUMAN CARE SERVICES Home Care..." 2. A review of the facility's incident reports revealed a document dated September 22, 2025. The document stated, "...[Resident] then began to physically assault [E1], striking [E1] multiple times in the face and neck, as [E1] attempted to restrain [resident] to prevent further escalation...but [resident] continued to physically assault [E1] as [E1] attempted to restrain [resident] from assaulting [E1] further..." 3. A review of E1's, E2's, and E3's personnel records revealed no documentation of training in emergency safety responses. 4. In an interview, E1 reported the facility does not use emergency safety responses and no personnel are trained to use emergency safety responses. E1 reported E1 had to restrain the resident in order to protect themselves from further injury. E1 reported, at the last inspection conducted on September 25, 2025, that E1 would have all personnel trained in emergency safety responses, however, has yet to do so. 5. In the exit interview, the findings were reviewed with E1. E1 reported all personnel would complete the training for emergency safety responses through Relias. No additional comments or documentation were provided.

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

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure sufficient personnel members were present on a behavioral health residential facility's premises with the qualifications, experience, skills, and knowledge necessary to provide the services in the behavioral health residential facility's scope of services. The deficient practice posed a health and safety risk as there were no qualified staff present to ensure the health and safety of the residents.

findings: 1. A review of the facility's policies and procedures revealed a document titled, " Scope of Services ." The document stated, "...Servicing individuals male or female under 18 years of age with varying degrees of mental health challenges and serious emotional disorders. Counseling for depression, bipolar, anxiety, substance abuse, relapse prevention...5. HUMAN CARE SERVICES Home Care is providing services 365 days per year, 24 hours per day. HUMAN CARE SERVICES home has the capacity for 10 beds, 2 staff members will be onsite on each shift to supervise and ensure the safety of all residents and to make sure the services are being provided..." 2. A review of R1's medical record revealed a document titled, "Minimum Elements of Behavioral Health Assessment." The document stated R1 was admitted to the behavioral health residential facility due to the following diagnoses: "F90.9 attention deficit hyperactivity disorder unspecified; F43.10 post traumatic stress disorder unspecified; F34.9 persistent mood (affective) disorder unspecified; Z62.810 personal history of physical and sexual abuse in childhood; Z63.79 Other stressful life events affecting family and household." 3. A review of Department documentation revealed a document titled "Intake Information Report." The document stated, "...Incident Date: 10/09/25 7:20 PM...[E2] was reported to got [sic] into a physical fight with 17 year old client...During the shift the incident happened no other staff was present but [E2]...." 4. A review of the facility's personnel schedules revealed a document titled "HCSI Schedule Current October." The document detailed two shifts per day on each day of the week, Monday through Sunday, 8:00 AM - 8:00 PM and 8:00 PM - 8:00 AM; however, the days of the week were not dated. The document listed one personnel name for each shift. Under "Thursday," (October 9, 2025), the document listed E2 as the only personnel present on the 8:00 AM - 8:00 PM shift. 5. A review of the facility's incident reports revealed a document dated October 9, 2025. The document stated, " [R1] became escalated after a meeting with the crisis team...refused medication, made allegation against staff...became emotionally distressed...Staff explained that night staff would arrive within 20 minutes and suggested waiting until then...[R1] began cursing at another client, leading to a verbal altercation. Additional staff arrived to assist...earlier in the day, both police and the crisis team had responded to separate incidents involving [R1] due to aggressive behavior and refusal to follow staff direction..." 6. A review of E2's personnel record revealed a document titled "Employment Application." The document stated E2 applied for the position of "Volunteer." The document revealed no evidence of any prior education or experience in the behavioral health field for E2. 7. A review of E2's personnel record revealed a professional resume for E2. The document revealed no evidence of any prior education or experience in the behavioral health field for E2. 8. In an interview, R1 and R2 reported E2 was the only personnel at the facility from 8:00 AM - 8:00 PM on October 9, 2025. 9. In an interview, E1 reported on October 9, 2025 the facility only had three residents. E1 reported when the facility has more than three residents, two personnel will be scheduled on each shift. E1 reported E2 was the only personnel on shift at the time of the incident on October 9, 2025. E1 acknowledged E2 did not have any documented evidence of education or experience in the behavioral health field. 10. In the exit interview, the findings were reviewed with E1 and no further comments or documentation was provided.

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

evidence: Based on documentation review and interview, the administrator failed to ensure that a resident was treated with dignity, respect, and consideration. The deficient practice posed a safety risk as R1, R2, and R3 exhibited inappropriate behavior towards each other due to not being provided with continuous protective oversight.

findings: 1. A review of the facility's incident reports revealed a document dated October 8, 2025. The document stated, "...Clients [R1], [R2], and [R3] was [sic] all involved in inappropriate relations putting hickies [sic] on each other while staff was in a CFT. All clients was [sic] talked to about the importance of being safe, personal boundaries, and consequences. All clients took accountability after denying in the beginning..." 2. In an interview, R1 reported R1, R2, and R3 had engaged in inappropriate behavior with each other but "not in a sexual way." R1 reported the three residents were in a "goofy mood" and R2 had the idea to give each other hickeys to be funny. R1 reported R2 and R3 gave R1 two hickeys on R1's neck and one on R1's thigh. R1 reported R2 was given hickeys on R2's neck by R1 and R3. R1 reported R3 was not given hickeys because R1 and R2 wanted to blame the hickeys on R3 if they got caught by staff. R1 reported staff were in a meeting when this occurred. 3. In an interview, R2 reported R1 and R3 gave R2 hickeys on R2's neck. R2 reported this was "just for fun" and was consensual. 4. In an interview, E1 confirmed R1, R2, and R3 gave each other hickeys while the staff was in a CFT meeting. E1 provided the Compliance Officer with a picture taken of the hickeys on R1's neck. 5. In the exit interview, the findings were reviewed with E1 and no additional documentation or comments were provided. This is a repeat citation from inspections conducted on October 31, 2023 and April 11, 2024.

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

evidence: Based on documentation review and interview, the administrator failed to ensure if a behavioral health residential facility was licensed to provide behavioral health services to individuals whose behavioral health issue limits the individuals' ability to function independently, a resident admitted to the behavioral health residential facility with limited ability to function independently received continuous protective oversight. The deficient practice posed a health and safety risk for residents under the age of 18.

findings: 1. A review of the facility's incident reports revealed a document dated October 8, 2025. The document stated, "...Clients [R1], [R2], and [R3] was [sic] all involved in inappropriate relations putting hickies [sic] on each other while staff was in a CFT. All clients was [sic] talked to about the importance of being safe, personal boundaries, and consequences. All clients took accountability after denying in the beginning..." 2. In an interview, R1 reported R1, R2, and R3 had engaged in inappropriate behavior with each other but "not in a sexual way." R1 reported the three residents were in a "goofy mood" and R2 had the idea to give each other hickeys to be funny. R1 reported R2 and R3 gave R1 two hickeys on R1's neck and one on R1's thigh. R1 reported R2 was given hickeys on R2's neck by R1 and R3. R1 reported R3 was not given hickeys because R1 and R2 wanted to blame the hickeys on R3 if they got caught by staff. R1 reported staff were in a meeting when this occurred. 3. In an interview, R2 reported R1 and R3 gave R2 hickeys on R2's neck. R2 reported this was "just for fun" and was consensual. 4. In an interview, E1 confirmed R1, R2, and R3 gave each other hickeys while the staff was in a CFT meeting. E1 provided the Compliance Officer with a picture taken of the hickeys on R1's neck. 5. In the exit interview, the findings were reviewed with E1, and no additional documentation or comments were provided. This is a repeat citation from an inspection conducted on October 31, 2023.


summary: Complaint - 9/25/2025

raw_content: The following deficiencies were found during the on-site investigation of complaints 00140932 and 00145806 conducted on September 25, 2025:

rule: R9-10-711.B.2.i. Resident Rights B. An administrator shall ensure that: 2. A resident is not subjected to: i. Restraint;

evidence: Based on observation, documentation review, and interview, the administrator failed to ensure a resident was not subjected to restraint, for one of four residents sampled. The deficient practice posed a risk for psychological distress or physical harm, and is not authorized in a behavioral health residential facility.

findings: R9-10-101.202. “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. 1. A review of a video from the facility's security camera footage, the Compliance Officer observed E3 restrain R2 by holding [R2's] arms behind [R2's] back. 2. A review of facility documentation revealed an incident report (dated in September 2025). The incident report stated, "During scheduled school hours, [R4] was observed becoming verbally aggressive and made threatening statements toward [R1]. When [E3] attempted to redirect [R4], [R4] escalated by gesturing as if to strike [R1], though no physical contact occurred. To de-escalate the situation, [E3] directed [R1] to the office to continue [R1's] school activities separately. Shortly after [R4 and R2] were observed proceeding upstairs to [R2's] bedroom, taking [R2's] school computer with them. [E3] attempted to redirect, explaining that taking school equipment upstairs was not permitted. At this point, [R1] informed [E3] that [R2 and R4] may have been attempting to send the group home's address to someone for the purpose of arranging a drug drop-off. [E3] immediately approached [R2's] room to retrieve the computer, along with a water bottle and night lights belonging to another client. As [E5] exited the room with the items, [R4] made additional threatening statements and began approaching [E5] in an aggressive manner. At this time, [E3] requested that [E5] hand the retrieved items to [E3]. As [E5] attempted to do so, [R4] attempted to grab the items unsuccessfully. [R4] then proceeded to physically assault [E3], striking [E3] multiple times in the face and neck as [E3] attempted to restrain [R4] from further escalation. [R2] then joined the altercation striking [E3] in the back and tearing [E3's] shirt. [E5] attempted to redirect [R2] but [R2] continued to physically assault [E3] as [E3] attempted to restrain [R4] from assaulting [E3] further. When [E5] attempted to call law enforcement, [R2] grabbed the phone and threw it against the wall, damaging the device. Maricopa Police Department was contacted and responded to the scene. Outcome: Upon arrival, Maricopa [Police Department] arrested both [R4] and [R2] on charges related to assault and property damage. Both [R2 and R4] were transported to Florence Jail without further incident." 3. In an interview, E3 reported E3 restrained R2; however, E3 reported doing it to protect the other residents. 4. In an exit interview, the findings were discussed with E3, and no additional documentation or statements were provided.

rule: R9-10-716.E.1.a.i. Behavioral Health Services 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 observation, documentation review, record 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 for psychological distress or physical harm, and E3 was not trained in emergency safety response.

findings: 1. A review of a video from the facility's security camera footage, the Compliance Officer observed E3 restrain R2 by holding [R2's] arms behind [R2's] back. 2. A review of the facility's incident reports revealed an incident report for R2 (dated in September 2025). The incident report contained documentation of a one-person hold involving R2 and E3. 3. A review of E3's personnel record revealed no documentation of emergency safety response training. 4. In an interview, E3 reported E3 restrained R2; however, E3 reported doing it to protect the other residents. 5. In an interview, E3 acknowledged E3 was not trained to use emergency safety response. 6. In an exit interview, the findings were discussed with E3, and no additional documentation or statements were provided.

rule: R9-10-719.B.2.d. Food Services B. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, a registered dietitian or director of food services shall ensure that: 2. A food menu: d. Includes any food substitution no later than the morning of the day of meal service with a food substitution, and

evidence: Based on documentation review and interview, the director of food services failed to ensure a food menu included any food substitution no later than the morning of the day of meal service with a food substitution. The deficient practice posed a risk if the source of a potential food borne illness could not be identified.

findings: 1. A review of facility documentation revealed a menu conspicuously posted and dated "Week 4." The menu indicated the following meal would be provided on September 25, 2025: Lunch: "Chicken Tenders [with] mashed potato and gravy, steamed broccoli, cornbread [with] margarine." 2. In an interview, R1 reported having taquitos for lunch on the aforementioned date. 3. In an interview, E3 stated the facility served "taquitos and beans" for lunch on the aforementioned date. 4. In an exit interview, E4 acknowledged food substitutions for the lunch meal were not posted the morning of the day of meal service with a food substitution.


summary: Complaint;Compliance (Annual) - 6/27/2025

raw_content: The following deficiencies were found during the on-site compliance inspection and investigation of complaint 00120825 conducted on June 27, 2025:

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

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel member's skills and knowledge were verified and documented before the personnel member provided physical health services or behavioral health services. The deficient practice posed a health and safety risk if the personnel member's skills and knowledge had not been verified to ensure proper delivery of services to residents.

findings: 1. A review of the facility policies and procedures dated in 2023 under the section titled “Employees and Volunteers Qualifications” stated, "The hiring person or manager will ensure, check, and document that the employee or volunteer providing physical health services or behavioral health services has the required skills and knowledge before providing any services." 2. A review of E2's personnel record revealed a document titled "Verification of Skills and Knowledge." However, the document was not signed by the administrator, indicating E2's skills and knowledge had been verified. 3. A review of R1's medical record (admitted in 2025) revealed E2 provided assistance in the self-administration of medication on June 6, 2025. 4. In an exit interview, no further information or documentation was provided.

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel member, employee, volunteer, or student, which included documentation of the individual's compliance with the requirements in A.R.S. § 8-804. The deficient practice posed a safety risk for residents if personnel did not clear a Department of Child Safety (DCS) registry check before working with vulnerable residents under 18 years of age.

findings: A.R.S. 8-804. states, "The department shall conduct central registry background checks and shall use the information contained in the central registry only for the following purposes: -As a factor to determine qualifications for any of the following: (g) An adult who works in a group home, residential treatment center, shelter, or other congregate care setting." 1. A review of Department documentation revealed BH8688 was licensed as a behavioral health residential facility to provide services to residents under the age of 18 in June 2023. 2. A review of E2's (hired in January 2025) and E3's (hired in May 2025) personnel records revealed a document titled "Direct Service Central Registry Clearance Form." The forms were completed by E2 and E3. However, the forms were not sent to DCS for processing. It is unknown if E1 and E2 had substantiated reports with DCS as a DCS registry check has not been completed. 3. In an exit interview, the findings were reviewed with E1, who did not provide additional comments or documentation.

rule: R9-10-707.A.6. Admission; Assessment 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. The deficient practice posed a health and safety risk if medical personnel did not have a baseline medical assessment on the resident to begin needed services.

findings: 1. A review of R1's medical record revealed no documentation of a medical history and physical examination or a nursing assessment dated within 30 calendar days before admission or within 72 hours after admission. E1 reported E1 would send the requested document via email. However, the document was never sent to the Compliance Officer. 2. In an exit interview, no further comments or documentation were provided.


summary: Complaint - 1/14/2025

raw_content: An on-site investigation of complaint AZ00221822 was conducted on January 14, 2025 and no deficiencies were cited.


summary: Complaint - 9/19/2024

raw_content: An on-site investigation of complaint AZ00215305 was conducted on September 19, 2024 and no deficiency was cited.