facility_name: R M B H S RENATA HOUSE

summary: Compliance (Annual) - 10/29/2025

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on October 29, 2025.

rule: R9-10-705.1-2. Contracted Services An administrator shall ensure that: 1. Contracted services are provided according to the requirements in this Article, and 2. Documentation of current contracted services is maintained that includes a description of the contracted services provided.

evidence: Based on observation, record review, and interview, the administrator failed to ensure contracted services were provided according to the requirements in Article Seven (7) and documentation of current contracted services was maintained, for one of three contracted personnel sampled. The deficient practice posed a risk as the administrator did not maintain a current contract for a registered dietitian (RD).

findings: 1. The Compliance Officer observed food menus for breakfast, lunch, dinner, and snacks, dated July 18, 2025, to July 20, 2025, posted on the refrigerator door in the facility’s kitchen. On the snack menu, adjacent to the July 2025 dates, several black ink lines had been drawn through “5-9 – 5-11,” appearing to conceal the original menu dates of May 9, 2025, to May 11, 2025. 2. A review of E6's personnel record revealed a document titled “Dietitian Agreement,” which stated, “This Agreement is made and entered into as of May 31, 2023, between [E6’s company]… and Red Mountain Behavioral Health Services, LLC… This Agreement will commence on the effective date and will remain in effect for one year, until May 31, 2024.” 3. The Compliance Officer requested the name of the registered dietitian assigned to the facility. E4 reported the contracted registered dietitian was E6. Following a telephone call with O1 at 09:35 AM, to locate a current contract with E6, O1 reported being unable to locate any documentation. 4. In an interview, E4 reported E5 served as the registered dietitian for a facility located in northern Arizona, and E6 had likely been terminated due to the facility no longer requiring two registered dietitians. E4 further reported they would contact O1 and E5 to obtain a valid contract between E5 and BH3631. 5. A review of facility documentation revealed the absence of a contract between the facility and a registered dietitian during the period of the on-site compliance inspection. 6. In an exit interview, the findings were discussed with E4 and E7, and no additional statements or documentation were provided.

rule: R9-10-721.A.1.c. Environmental Standards A. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 1. The premises and equipment are: c. Free from a condition or situation that may cause a resident or other individual to suffer physical injury;

evidence: Based on observation and interview, the administrator failed to ensure that the premises and equipment were maintained free from conditions or situations that could cause a resident or other individual to suffer physical injury. This deficient practice posed a risk to the physical health and safety of individuals and the failure to identify and correct the hazard in a timely manner increased the likelihood of injury to any individual in the area.

findings: 1. The Compliance Officer observed a ragged, welded piece of metal protruding from the ground in the facility’s backyard. The metal piece had been set in concrete for prior use as a recreational fixture, such as a tetherball pole or outdoor umbrella stand, and presented a potential safety hazard to individuals in the area. 2. In an interview, E4 reported being unaware of when the protruding metal piece had been removed and left in its current condition. E4 also reported they would go outside, take a photograph of the hazard, and submit it to the facility’s maintenance team for removal. 3. In an exit interview, the findings were discussed with E4 and E7, and no additional statements or documentation were provided.


state: AZ

summary: Compliance (Annual) - 10/16/2024

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on October 16, 2024.

inspection_type: Compliance (Annual)

rule: A. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 15. Combustible or flammable liquids and hazardous materials stored by a behavioral health residential facility are stored in the original labeled containers or safety containers in a locked area inaccessible to residents;

evidence: Based on observation and interview, the administrator failed to ensure combustible or flammable liquids and hazardous materials stored by a behavioral health residential facility were stored in a locked area inaccessible to residents.

findings: 1. The Compliance Officer observed the following combustible or flammable liquids, in an unlocked cabinet, in the kitchen: -Dr. Scholl's Odor-X -Kroger Sport sunscreen spray - Glade air freshner The items contained combustible and/or flammable warning labels. 2. In an interview, E1 acknowledged the combustible or flammable liquids and hazardous materials stored by the facility were not locked and were accessible to the residents.


summary: Compliance (Annual) - 10/4/2023

raw_content: This new Statement of Deficiencies supercedes the Statement of Deficiencies sent to the licensee on October 10, 2023. The following deficiencies were found during the on-site compliance inspection conducted on October 4, 2023:

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

evidence: Based on record review and interview, the administrator failed to ensure a personnel record was maintained to include documentation of A.R.S. \'a7 36-411(C)(1)(2), for two of two behavioral health technicians sampled.

findings: A.R.S. \'a7 36-411(C)(1)(2) Owners shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency; 2. Verify the current status of a person's fingerprint clearance card. 1. A review of E3's personnel record revealed a valid fingerprint clearance card. However, documentation of compliance with A.R.S. \'a7 36-411(C)(1)(2) was not available for review. 2. A review of E4's personnel record revealed a valid fingerprint clearance card. However, documentation of compliance with A.R.S. \'a7 36-411(C)(1)(2) was not available for review. 3. In a joint interview, E1 and E2 acknowledged E3's and E4's personnel records did not include documentation in compliance with A.R.S. \'a7 36-411(C)(1)(2).

rule: B. An administrator shall ensure that counseling is: 1. Offered as described in the behavioral health residential facility's scope of services,

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure counseling was offered as described in the behavioral health residential facility's scope of services. The deficient practice posed a risk as a behavioral health service listed in the behavioral health residential facility's scope of services was not provided on the premises.

findings: R9-10-101(36) "Behavioral health residential facility" means a health care institution that provides treatment to an individual experiencing a behavioral health issue that: a. Limits the individual's ability to be independent, or b. Causes the individual to require treatment to maintain or enhance independence. R9-10-101(238) "Treatment" means a procedure or method to cure, improve, or palliate an individual's medical condition or behavioral health issue. R9-10-101 (29) "Behavioral health issue" means an individual's condition related to a mental disorder, a personality disorder, substance abuse, or a significant psychological or behavioral response to an identifiable stressor or stressors. R9-10-101(200) "Respite services" means respite care services provided to an individual who is receiving behavioral health services. A.R.S. 36-401(A)(11) "Behavioral health services" means services that pertain to mental health and substance use disorders and that are either (a) Performed by or under the supervision of a professional who is licensed pursuant to title 32 and whose scope of practice allows the professional to provide these services. (b) Performed on behalf of patients by behavioral health staff as prescribed by rule. ARS \'a7 36-401(A)(45) "Respite care services" means services that are provided by a licensed health care institution to persons who are otherwise cared for in foster homes and in private homes to provide an interval of rest or relief of not more than thirty days to operators of foster homes or to family members. 1. A review of facility documentation revealed the facility's scope of services (dated April 1, 2023) stated: "Behavioral Health Services: -Are provided to clients with similar treatment needs, diagnoses, developmental levels, verbal and social skills, and any personal history that includes physical or sexual abuses when involved in an activity or setting that includes more than one client; -Protects the health and safety of each client; -Meets the treatment needs for each client; -Are provided under the direction of a Behavioral Health Professional (BHP); -Comply with the R9-10-1011(B) requirements for completing assessments; -RMBHS will not provide services that they are not authorized to provide; -Respite Services; and -Wellness Weekend Program may provide specialty services that include: 1:1 client care ..." 2. A review of R1's medical record revealed a behavioral health assessment (BHA) dated in January 2023. The BHA indicated R1's presenting issues included: "...struggles with focus and sitting still and picking scabs until they bleed...has a history of being extremely aggressive...boundary issues..." [R1] was diagnosed with: "ADHD...Adjustment disorder." 3. A review of R1's medical record revealed a treatment plan dated in July 2023. The treatment plan revealed R1 was to "attend Wellness as needed or at least 1x every 6 weeks..." 4. A review of R2's medical record revealed a BHA dated in June 2022. The BHA indicated R2's presenting issues included: "...difficulty sharing (communicating) with [R2's] siblings..." [R2] was diagnosed with: "Adjustment disorder...Other specified trauma and stressor related to disorder..." 5. A review of R2's medical record revealed a treatment plan dated in July 2023. The treatment plan revealed R2 was to "attend Wellness as needed or at least 1x every 6 weeks..." 6. In an interview, E1 reported the "Wellness Program" was the respite care services residents received on the weekends at BH3631. 7. In an interview, E2 reported counseling services were not provided to R1 and R2 at BH3631.


facility_name: R M B H S SOMERSET HOUSE

summary: Complaint;Compliance (Annual) - 10/29/2025

raw_content: No deficiencies were found during the on-site compliance inspection and investigation of complaint 00136597 conducted on October 29, 2025.

inspection_type: Complaint;Compliance (Annual)


summary: Compliance (Annual) - 10/9/2024

raw_content: No deficiencies were found during the on-site compliance inspection conducted on October 9, 2024.


summary: Compliance (Annual) - 10/4/2023

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure counseling was offered as described in the behavioral health residential facility's scope of service, for two of two residents sampled. The deficient practice posed a risk as a behavioral health service listed in the behavioral health residential facility's scope of services was not provided on the premises.

findings: R9-10-101(36) "Behavioral health residential facility" means a health care institution that provides treatment to an individual experiencing a behavioral health issue that: a. Limits the individual's ability to be independent, or b. Causes the individual to require treatment to maintain or enhance independence. R9-10-101(238) "Treatment" means a procedure or method to cure, improve, or palliate an individual's medical condition or behavioral health issue. R9-10-101 (29) "Behavioral health issue" means an individual's condition related to a mental disorder, a personality disorder, substance abuse, or a significant psychological or behavioral response to an identifiable stressor or stressors. R9-10-101(200) "Respite services" means respite care services provided to an individual who is receiving behavioral health services. A.R.S. 36-401(A)(11) "Behavioral health services" means services that pertain to mental health and substance use disorders and that are either (a) Performed by or under the supervision of a professional who is licensed pursuant to title 32 and whose scope of practice allows the professional to provide these services. (b) Performed on behalf of patients by behavioral health staff as prescribed by rule. ARS \'a7 36-401(A)(45) "Respite care services" means services that are provided by a licensed health care institution to persons who are otherwise cared for in foster homes and in private homes to provide an interval of rest or relief of not more than thirty days to operators of foster homes or to family members. 1. A review of facility documentation revealed the facility's scope of services (dated April 1, 2023) stated: "Behavioral Health Services: -Are provided to clients with similar treatment needs, diagnoses, developmental levels, verbal and social skills, and any personal history that includes physical or sexual abuses when involved in an activity or setting that includes more than one client; -Protects the health and safety of each client; -Meets the treatment needs for each client; -Are provided under the direction of a Behavioral Health Professional (BHP); -Comply with the R9-10-1011(B) requirements for completing assessments; -RMBHS will not provide services that they are not authorized to provide; -Respite Services; and -Wellness Weekend Program may provide specialty services that include: 1:1 client care ..." 2. A review of R1's medical record revealed a behavioral health assessment (BHA) dated in August 2022. The BHA indicated R1's presenting issues included: "...struggles with telling the truth...struggles with lying and taking things..." [R1] was diagnosed with: "Adjustment disorder...ADHD, combined type." 3. A review of R1's medical record revealed a treatment plan dated in August 2023. The treatment plan revealed R1 was to "attend Wellness as needed or at least 1x every 6 weeks..." 4. A review of R2's medical record revealed a BHA dated in December 2022. The BHA indicated R2's presenting issues included: "...tantrums and will throw things and scream..." 5. A review of R2's medical record revealed a treatment plan dated in June 2023. The treatment plan revealed R2 was to "attend Wellness as needed or at least 1x every 6 weeks..." 6. In an interview, E1 reported the "Wellness Program" was the respite care services residents received on the weekends at BH3632. 7. In an interview, E2 reported counseling services were not provided to R1 and R2 at BH3632.


facility_name: R M B H S COGDELL HOUSE

summary: Compliance (Annual) - 10/22/2025

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on October 22, 2025.

rule: R9-10-712.A.7. Medical Records A. An administrator shall ensure that: 7. A resident's medical record is protected from loss, damage, or unauthorized use.

evidence: Based on observation and interview, the administrator failed to ensure resident medical records were protected from loss, damage, or unauthorized use. The deficient practice posed a risk of protected sensitive resident health information being disclosed without the resident's consent or knowledge.

findings: 1. The Compliance Officer observed an unsecured and accessible closet in the facility’s privacy room containing two medication bottles with medication inside and a resident’s protected health information. 2. The Compliance Officer brought the items to E1 and E6 in the facility’s dining room and placed them on the table for E1 or E6 to secure. 3. In an exit interview, the findings were reviewed with E1 and E6, and no further documentation or comments were provided.

rule: R9-10-712.C.7. Medical Records C. An administrator shall ensure that a resident's medical record contains: 7. Documentation of medical history and results of a physical examination;

evidence: Based on record review and interview, the administrator failed to ensure a resident's medical record contained documentation of medical history and results of a physical examination, for two of two residents sampled. The deficient practice posed a risk of not meeting a resident's needs if no medical history and physical examination were completed to assess a resident's needs prior to treatment.

findings: 1. A review of R1’s and R2's medical records revealed no documentation of a medical history or results of a physical examination. 2. In an interview, E1 reported R1 and R2 completed a physical examination, but the documentation was missing from both medical records. 3. In an exit interview, the findings were reviewed with E1 and E6, and no further documentation or comments were provided.

rule: R9-10-718.E.1. Medication Services E. When medication is stored at a behavioral health residential facility, an administrator shall ensure that: 1. Medication is stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage;

evidence: Based on observation, documentation review, and interview, the administrator failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for storage medication. The deficient practice posed a risk to the health and safety of residents if residents were able to have access to medication not prescribed to them and the standards expected of employees in the policies and procedures were not followed.

findings: 1. The Compliance Officer observed an unsecured and accessible closet in the facility’s privacy room containing two medication bottles with medication inside, one Sertraline 50MG and the other Trazodone 50MG, and a resident’s protected health information. 2. The Compliance Officer brought the items to E1 and E6 in the facility’s dining room and placed them on the table for E1 or E6 to secure. 3. A review of facility documentation revealed a policy titled "Assistance in the Self-Administration Medications [sic]" (dated on April 1, 2023). The procedure stated, "Medication is stored in a separate locked room, closet, cabinet, or self-contained unit that is used only for medication storage and is maintained under trained and qualified staff supervision." 4. In an exit interview, the findings were reviewed with E1 and E6, and no further documentation or comments were provided.

rule: R9-10-719.C.1. Food Services C. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that food is obtained, prepared, served, and stored as follows: 1. Food is free from spoilage, filth, or other contamination and is safe for human consumption;

evidence: Based on observation and interview, the administrator failed to ensure food was free from spoilage, filth, contamination, and was safe for human consumption. The deficient practice posed a risk to infection control and standards expected of employees were not followed.

findings: 1. The Compliance Officer observed spoiled, molded, and expired food inside the refrigerator in the facility’s kitchen. 2. In an interview, E1 reported no residents had occupied the facility since around mid-August 2025. 3. In an exit interview, the findings were reviewed with E1 and E6, and no further documentation or comments were provided.

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. The deficient practice posed a risk if employees were unable to implement a disaster plan.

findings: 1. A review of facility documentation revealed no evidence of disaster drills conducted on each shift at least once every three months from the past 12 months of the on-site compliance inspection dated on October 22, 2025. 2. In an interview, E6 reported attempting to locate disaster drills; however, none were found 3. In an exit interview, the findings were reviewed with E1 and E6, and no further documentation or comments were provided.

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

evidence: Based on documentation review and interview, the administrator failed to ensure an evacuation drill for employees and residents on the premises was conducted at least once every six months on each shift. The deficient practice posed a risk if the employees were not able to implement the disaster plan in the case of the need to evacuate in an emergency.

findings: 1. A review of the facility documentation revealed no documentation or evidence evacuation drills were conducted for employees and residents at least once every six months on each shift from the past 12 months of the on-site compliance inspection dated on October 22, 2025. 2. In an interview, E6 reported attempting to locate evacuation drills; however, none were found 3. In an exit interview, the findings were reviewed with E1 and E6, and no further documentation or comments were provided.

rule: R9-10-721.A.6.b. Environmental Standards A. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 6. Garbage and refuse are: b. Removed from the premises at least once a week;

evidence: Based on observation and interview, the administrator failed to ensure garbage and refuse were removed from the premises at least once a week. The deficient practice posed a potential risk to infection control and the standards expected of employees were not followed.

findings: 1. The Compliance Officer observed a half-full garbage can and a dead cockroach on the floor beside the container located in a resident bathroom. 2. The Compliance Officer observed a black nightstand with garbage and refuse on top and on the floor beside it located in a resident bedroom. 3. The Compliance Officer observed a half-full garbage can containing bags with snacks and cups in the large classroom-style room of the facility. 4. The Compliance Officer observed an overfilled garbage can containing various trash and debris in a room leading to the facility’s backyard. 5. The Compliance Officer observed various garbage and refuse scattered beneath a cabinet under the sink in a resident bathroom. 6. In an interview, E1 reported no residents had occupied the facility since around mid-August 2025. 7. In an exit interview, the findings were reviewed with E1 and E6, and no further documentation or comments were provided.

rule: R9-10-722.B.8.i. Physical Plant Standards B. An administrator shall ensure that: 8. A resident bedroom complies with the following: i. Has clean linen for each bed including mattress pad, sheets large enough to tuck under the mattress, pillows, pillow cases, bedspread, waterproof mattress covers as needed, and blankets to ensure warmth and comfort for each resident;

evidence: Based on documentation review, observation, and interview, the administrator failed to ensure a resident bedroom had clean linen for each bed to include a mattress pad, sheets large enough to tuck under the mattress, pillows, pillow cases, bedspread, waterproof mattress covers as needed, and blankets to ensure warmth and comfort for each resident. The deficient practice posed a risk as failure to maintain a resident bedroom demonstrated a lack of readiness to safely and comfortably accommodate residents in accordance with licensing standards, and the standards expected of employees were not followed.

findings: 1. The Compliance Officer observed resident bedrooms did not contain clean linens for each bed to include a mattress pad, sheets large enough to tuck under the mattresses, pillows, pillow cases, bedspreads, and blankets. 2. In an interview, E1 reported no residents had occupied the facility since around mid-August 2025. 3. In an exit interview, the findings were reviewed with E1 and E6, and no further documentation or comments were provided.


summary: Complaint - 1/28/2025

raw_content: An on-site investigation of complaint AZ00222580 was conducted on January 28, 2025 and the following deficiencies were cited :

inspection_type: Complaint

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

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure sufficient personnel members were present on a behavioral health residential facility's premises with the qualifications, experience, skills, and knowledge necessary to ensure the health and safety of a resident. The deficient practice posed a risk as R1 and R2 left the facility without continuous protective oversight as E6 was the only personnel member working, and if E6 was unable to meet a resident's needs during an emergency or during an accident.

findings: 1. A review of Department documentation revealed BH3633 was licensed to provide behavioral health services to individuals whose behavioral health issue limits the individuals' ability to function independently (individuals under 18 years of age). 2. A review of facility documentation revealed a policy and procedure titled "Staff Coverage, Continuous Protective Oversight" (dated December 2, 2024). The policy and procedure stated " ... 1. Staff Presence: The Administrator will ensure that staff members are present and available to monitor and support residents. This includes having sufficient staff on duty 24/7 to provide immediate assistance if needed." 3. A review of facility documentation revealed a document titled "Incident Report" (dated January 20, 2025). The document stated " ... Staff/Witness Name(s)/ and Contact Info: [E6] ... At approximately eight pm [R1] from the Hermosa Vista facility while the staff members was de-escalating a patient (unknown). The staff member stepped outside to check and ensure the patient (R1) wasn't visible once this was clarified the police was called." 4. A review of facility documentation revealed a document titled "Incident Report" (dated January 20, 2025). The document stated " ... At approximately eight PM, [R2] Awol from the Hermosa Vista RTC while the staff member was de-escalating another patient [unknown]. The staff member walked outside to visibly check and ensure the patient (R2)could not be seen before the police were called ... once back in the care of Hermosa Vista, the patient (unknown) remained stable for the rest of the shift." 5. In an interview, E1 reported E6 was the only personnel member present during the aforementioned incident. 6. In an interview, E1 reported E6 was considered a house program manager/behavioral health technician. 7. In a joint exit interview, the findings were reviewed with E1, E2, and E3 and no additional comments, statements, or documentation were provided regarding the findings.

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: a. The individual's qualifications, including skills and knowledge applicable to the individual's job duties;

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 skills and knowledge, for two of three personnel members sampled. The deficient practice posed a risk if E4 and E6 were unable to meet a resident's needs.

findings: 1. A review of facility documentation revealed a policy and procedure titled "Orientation" (dated November 30, 2024). The policy and procedure stated " ... A personnel member's skills and knowledge are verified by the hiring manager in a programmatic or clinical managerial role and documented according to policies and procedures." 2. A review of E4's (hired in 2025) personnel record revealed E4 was hired as a behavioral health technician (BHT). However, documentation to demonstrate E4's skills and knowledge were verified and documented was not available for review. 3. In an interview, E3 reported E4's skills and knowledge were verified and documented, however, this documentation was not available for review. E3 reported E6 had this documentation. 4. A review of E6's (hired in 2024) personnel record revealed E6 was hired as an "RTC Manager." However, documentation to demonstrate E6's skills and knowledge were verified and documented was not available for review. 5. In an interview, E1 reported E6 was considered a house program manager/behavioral health technician. 6. In an interview, E3 reported E6 was no longer employed with BH3633. 7. In an interview, E3 reported E6's skills and knowledge were verified and documented, however, this documentation was not available for review. 8. In a joint exit interview, the findings were reviewed with E1, E2, and E3 and no additional comments, statements, or documentation were provided regarding the findings.

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 as required by policies and procedures, for two of three personnel members sampled. The deficient practice posed a risk if E4 and E6 were unable to meet a resident's needs.

findings: 1. A review of facility documentation revealed a policy and procedure titled "Orientation" (dated November 30, 2024). The policy and procedure stated " ... 1. EmotiCare will ensure that all new employees attend a new-hire orientation." 2. A review of E4's (hired in 2025) personnel record revealed E4 was hired as a behavioral health technician (BHT). However, documentation of completed orientation was not available for review. 3. In an interview, E3 reported E4 completed orientation however, this documentation was not available for review. 4. A review of E6's (hired in 2024) personnel record revealed E6 was hired as an "RTC Manager." However, documentation of completed orientation was not available for review. 5. In an interview, E1 reported E6 was considered a house program manager/behavioral health technician. 6. In an interview, E3 reported E6 was no longer employed with BH3633. 7. In an interview, E3 reported E6 completed orientation, however, this documentation was not available for review. 8. In a joint exit interview, the findings were reviewed with E1, E2, and E3 and no additional comments, statements, or documentation were provided regarding the findings.

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 documentation review, 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 two of three personnel members sampled. The deficient practice posed a risk if E4 and E6 were unable to meet a resident's needs during an accident or emergency.

findings: 1. A review of facility documentation revealed a policy and procedure titled "Staff Coverage, Continuous Protective Oversight" (dated December 2, 2024). The policy and procedure stated " ... 5. At least one staff member who is certified in CPR and First Aid will be present in the facility at all times when clients are present." 2. A review of E4's (hired in 2025) personnel record revealed E5 was hired as a behavioral health technician (BHT). However, documentation of CPR training and first aid training was not available for review. 3. In an interview, E3 reported E4 took a CPR and first aid class on Thursday, January 23, 2025, however, this documentation was not available for review. E3 reported the first aid instructor was no longer employed with the company. 4. A review of E6's (hired in 2024) personnel record revealed E6 was hired as an "RTC Manager." However, E6's personnel record revealed documentation of first aid training was not available for review. 5. In an interview, E1 reported E6 was considered a house program manager/behavioral health technician. 6. In an interview, E3 reported E6 took a first aid class on Thursday, January 23, 2025, however, this documentation was not available for review. E3 reported the first aid instructor was no longer employed with the company. E3 reported E6 was no longer employed with BH3633. 7. In an interview, E1 reported E1 was working with upper management to obtain E4's documentation of CPR training and first aid training. 8. In a joint exit interview, the findings were reviewed with E1, E2, and E3 and no additional comments, statements, or documentation were provided regarding the findings.

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, record review, and interview, the administrator failed to ensure, a behavioral health residential facility licensed to provide behavioral health services to individuals whose behavioral health issue limits the individuals' ability to function independently, a resident admitted to the behavioral health residential facility with limited ability to function independently received continuous protective oversight. The deficient practice posed a risk as R1 and R2 left the facility without continuous protective oversight.

findings: 1. A review of Department documentation revealed BH3633 was licensed to provide behavioral health services to individuals whose behavioral health issue limits the individuals' ability to function independently (individuals under 18 years of age). 2. A review of facility documentation revealed a policy and procedure titled "Staff Coverage, Continuous Protective Oversight" (dated December 2, 2024). The policy and procedure stated " ... 1. Staff Presence: The Administrator will ensure that staff members are present and available to monitor and support residents. This includes having sufficient staff on duty 24/7 to provide immediate assistance if needed." 3. A review of facility documentation revealed a document titled "Incident Report" (dated January 20, 2025). The document stated " ... Staff/Witness Name(s)/ and Contact Info: [E6] ... At approximately eight pm [R1] from the Hermosa Vista facility while the staff members was de-escalating a patient (unknown). The staff member stepped outside to check and ensure the patient (R1) wasn't visible once this was clarified the police was called." 4. A review of facility documentation revealed a document titled "Incident Report" (dated January 20, 2025). The document stated " ... At approximately eight PM, [R2] Awol from the Hermosa Vista RTC while the staff member was de-escalating another patient [unknown]. The staff member walked outside to visibly check and ensure the patient (R2)could not be seen before the police were called ... once back in the care of Hermosa Vista, the patient (unknown) remained stable for the rest of the shift." 5. In an interview, E1 reported R1 went to the nearby grocery store where R1 was found by the police. 6. In an interview, E1 reported E6 was the only personnel member present during the aforementioned incident. 7. In a joint exit interview, the findings were reviewed with E1, E2, and E3 and no additional comments or statements were provided regarding the findings.


summary: Compliance (Annual) - 10/9/2024


summary: Compliance (Annual) - 10/4/2023

raw_content: This new Statement of Deficiencies superceds the Statement of Deficiencies mailed to the licensee of October 10, 2023. The following deficiencies were found during the on-site compliance inspection conducted on October 4, 2023:

findings: A.R.S. \'a7 36-411(C)(1)(2) Owners shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency; 2. Verify the current status of a person's fingerprint clearance card. 1. A review of E3's personnel record revealed a valid fingerprint clearance card. However, documentation of compliance with A.R.S. \'a7 36-411(C)(1)(2) was not available for review. 2. A review of E4's personnel record revealed a valid fingerprint clearance card. However, documentation of compliance with A.R.S. \'a7 36-411(C)(1)(2) was not available for review. 3. In a joint interview, E1 and E2 acknowledged E3's and E4's personnel records did not include documentation of compliance with A.R.S. \'a7 36-411(C)(1)(2).

evidence: Based on documentation review, record review, and interview, the administrator failed to counseling was offered as described in the behavioral health residential facility's scope of services, for two of two residents sampled. The deficient practice posed a risk as a behavioral health service listed in the behavioral health residential facility's scope of services was not provided on the premises.

findings: R9-10-101(36) "Behavioral health residential facility" means a health care institution that provides treatment to an individual experiencing a behavioral health issue that: a. Limits the individual's ability to be independent, or b. Causes the individual to require treatment to maintain or enhance independence. R9-10-101(238) "Treatment" means a procedure or method to cure, improve, or palliate an individual's medical condition or behavioral health issue. R9-10-101 (29) "Behavioral health issue" means an individual's condition related to a mental disorder, a personality disorder, substance abuse, or a significant psychological or behavioral response to an identifiable stressor or stressors. R9-10-101(200) "Respite services" means respite care services provided to an individual who is receiving behavioral health services. A.R.S. 36-401(A)(11) "Behavioral health services" means services that pertain to mental health and substance use disorders and that are either (a) Performed by or under the supervision of a professional who is licensed pursuant to title 32 and whose scope of practice allows the professional to provide these services. (b) Performed on behalf of patients by behavioral health staff as prescribed by rule. ARS \'a7 36-401(A)(45) "Respite care services" means services that are provided by a licensed health care institution to persons who are otherwise cared for in foster homes and in private homes to provide an interval of rest or relief of not more than thirty days to operators of foster homes or to family members. 1. A review of facility documentation revealed the facility's scope of services (dated April 1, 2023) stated: "Behavioral Health Services: -Are provided to clients with similar treatment needs, diagnoses, developmental levels, verbal and social skills, and any personal history that includes physical or sexual abuses when involved in an activity or setting that includes more than one client; -Protects the health and safety of each client; -Meets the treatment needs for each client; -Are provided under the direction of a Behavioral Health Professional (BHP); -Comply with the R9-10-1011(B) requirements for completing assessments; -RMBHS will not provide services that they are not authorized to provide; -Respite Services; and -Wellness Weekend Program may provide specialty services that include: 1:1 client care ..." 2. A review of R1's medical record revealed a behavioral health assessment (BHA) dated in February 2022. The BHA indicated R1's presenting issues included: "...aggressive behavior...anger outbursts." [R1] was diagnosed with: "Posttraumatic Stress Disorder." 3. A review of R1's medical record revealed a treatment plan dated in August 2023. The treatment plan revealed R1 was to "attend Wellness as needed or at least 1x every 6 weeks..." 4. A review of R2's medical record revealed a BHA dated in June 2022. The BHA indicated R2's presenting issues included: "...difficulty managing anger as well as depression..isolates, withdrawing from others...feeling sad...uncontrolled anger..." [R2] was diagnosed with "Depression..." 5. A review of R2's medical record revealed a treatment plan dated in April 2023. The treatment plan revealed R2 was to "attend Wellness as needed or at least 1x every 6 weeks..." 6. In an interview, E1 reported the "Wellness Program" was the respite care services residents received on the weekends at BH3633. 7. In an interview, E2 reported counseling services were not provided to R1 and R2 at BH3633.


facility_name: R M B H S LAKEVIEW HOUSE

summary: Compliance (Annual) - 3/13/2026

raw_content: No deficiencies were found during the on-site compliance inspection conducted on March 13, 2026.


summary: Compliance (Annual) - 2/25/2025

raw_content: No deficiencies were found during the on-site compliance inspection conducted on February 25, 2025.


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

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on February 7, 2024:

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel record was maintained to include documentation of Arizona Revised Statutes (A.R.S.) \'a7 36-411(C)(1), for two of two behavioral health technicians sampled. The deficient practice posed a risk if the personnel members were unfit to work in a residential care institution.

findings: 1. A.R.S. \'a7 36-411(C)(1) states: "C. Owners shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency." 2. A review of E3's and E4's personnel records revealed valid fingerprint clearance cards. However, documentation of compliance with A.R.S. \'a7 36-411(C)(1) for E3 and E4 was not provided for review. 3. In an interview, E1 reported the facility started implementing a new reference verification process after the compliance inspection conducted on February 14, 2023. E1 acknowledged E3's and E4's personnel records did not include documentation of compliance with A.R.S. \'a7 36-411(C)(1).

rule: E. If a behavioral health residential facility is authorized to provide respite services, an administrator shall ensure that: 1. Upon admission of a resident for respite services: a. Except as provided in subsection (F), a medical history and physical examination of the resident: i. Is performed; or ii. If dated within the previous 12 months, is available in the resident's medical record from a previous admission to the behavioral health residential facility;

evidence: Based on record review and interview, the administrator failed to ensure upon admission of a resident for respite services, a medical history and physical examination of the resident was performed. The deficient practice posed a risk if the facility was unable to meet the needs of a resident.

findings: 1. A review of R1's medical record revealed R1 was admitted to the facility for respite services. R1's medical record revealed no documentation to indiate a medical history and physical examination of the resident was performed when R1 was admitted to the facility. 2. In an interview, E1 reported E1 believed participants in the facility's program did not need to complete a medical history and physical examination. E1 reported the facility used a medical history completed by an outside health care agency to determine R1's treatment needs. E1 acknowledged R1 did not have a medical history or physical examination performed upon admission to the facility for respite services.


summary: Change of Service - 6/13/2023

raw_content: No deficiencies were found during the off-site inspection to modify the facility's licensed bed capacity, from eight to seven, completed on June 13, 2023.

inspection_type: Change of Service


facility_name: R M B H S PLATA HOUSE

summary: Compliance (Annual) - 3/13/2026


summary: Complaint;Compliance (Annual) - 3/5/2025

raw_content: The following deficiencies were found during the on-site compliance inspection and investigation of complaint 00107162 conducted on March 5, 2025:

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

evidence: Based on record review, documentation review, and interview, the health care institution's chief administrative officer failed to implement tuberculosis (TB) infection control activities which included annual training and education related to recognizing the signs and symptoms of TB to individuals employed by the health care institution, for three of ten personnel records sampled. The deficient practice posed a potential TB exposure risk to residents.

findings: 1. A review of E1's, E3's, and E4's personnel records revealed annual training and education related to recognizing the signs and symptoms of TB were not available for review. 2. A review of facility policies and procedures revealed a policy titled "In-Service Education Plan" (dated on April 1, 2024). The procedure stated, "This policy applies to all staff providing direct client care for RMBHS... RMBHS staff are required to complete the following in-service education annually: Infection Prevention and Communicable Diseases training (TB education)..." 3. In an interview, O2 reported personnel members who provided direct client care for the facility were required to have annual training on TB education which was electronically completed through Relias. 4. In an exit interview, E1, O1, and O3 reviewed the findings and no additional documentation was provided.

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, documentation 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. 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: 1. A review of the facility's policies and procedures revealed a policy titled "In-Service Education Plan" (dated April 1, 2024). The procedure stated, "Direct care staff who will be providing assistance in the self-administration of medication will complete a training annually." 2. A review of E8's personnel record (hired in June 2023) revealed a document titled "Subject: Separation of Employment" (dated in July 2024). The document stated, "To [E8], This letter serves to confirm that [E8's] employment with RMBHS ended as of [July 2024]. The reason for this separation is termination. This job requires competency in the self-administration of medication. Reasons: [E8] has received a total of 3 self-administering medication errors and one oversight medication error within the last year. [E8] has received an accumulated total of 9 weeks of oversight due to [E8's] medication errors within the last year. [E8] has received a total of 4 medication refreshers within the last year due to [E8's] medication errors. Medication Error on [July 2024]... [E8] acknowledged the error, however, was unaware the error existed until a manager reviewed the medication log on Sunday [July 2024]. [E8] did set alarms for specific medications for the weekend; However, due to this medication not being time specific no alarm was created by [E8]. [E8's] feedback was acknowledged that [E8] did miss the dose and had no reconciliation of self-administering medication on [July 2024]." 3. A review of R2's medical record (admitted in 2024) revealed a behavioral health assessment which stated "MEDICAL HISTORY: Guardian reports that [R2] has epilepsy and is on medication for maintenance. Last seizure was April 2023... MEDICATIONS (CURRENT & PAST): [R2] is currently prescribed Zonisamide 150mg, Lithium carbonate 300mg. Propranolol 10mg, Mirtazapine 7.5, Mirtazapine 15mg, Seroquel 100mg, Trazodone 100mg. Quetiapine 400mg, and Melatonin 5mg... TREATMENT RECOMMENDATIONS: ...[R2] will receive supervision during self-administration of medication while in care." 4. A review of R2's medical record revealed a medication administration record (MAR) dated in May 2024. The MAR stated "Medication Name: Propranolol... Dosage: 10mg... Directions/Route/Frequency: Take 1 tablet by mouth twice daily for anxiety... Starting Amount: 5 tab... Staff 1 [Initials of E7]... Date: [May 2024 - first day]... Time: 2041... Dose: 1... Staff 1 [Initials of E7]... Date: [May 2024 - second day]... Time: 2056... Dose: 1.... Staff 1 [Initials of E7]... Date: [May 2024]... Time: 0857... Dose: 1... Staff 1 [Initials of E7]... Remaining Amount: 2 tab..." and the printed name and signature of E7 for the weekend in May 2024 in which R2 took the medications. 5. A review of facility documentation revealed a document titled "Arizona Health Care Cost Containment System... INCIDENT, ACCIDENT OR DEATH REPORT" (IAD) dated in May 2024. The IAD stated, "It was discovered by staff during supervision of self-administration of medication on Sunday [May 2024] at 10am, that [R2's] prescribed morning dose of Propranolol 10mg had been missed the previous day [May 2024]. Staff called poison control at 10:40am to obtain guidance on how to proceed following missed medication dosage. Poison control advised that [R2] should resume with scheduled evening dosage as prescribed on [March 2024]. Staff contacted clients [sic] guardian, who agreed with Poison Controls [sic] directive to resume medication that evening. Staff attempted to outreach [sic] the prescribing physician at 10:45am to inform of missed dosage but was unable to make contact or leave a message at the time... INCIDENT TYPE: Safety/Risk Management... WITNESSES... [E7 and E4]... ACTION TAKEN AND/OR RECOMMENDED... Staff contacted management to notify of missed medication dosage at 10:30am. Following coordination with poison control, staff contacted the member's guardian to inform of missed dosage and discuss recommendations made by poison control. Guardian expressed agreement with poison control's recommendation to continue with [R2] self-administering medication at that [sic] the next scheduled dose. Actions to be taken to reduce risk of similar errors in the future will be for staff member responsible... CLINICAL DIRECTOR REVIEW... Staff informed manager upon recognition of medication error, Manager followed RMBHS Policy and Procedures by contacting program director, poison control, guardian, prescribing physician, and case manager. Staff member, [E4], will receive 1:1 clinical oversight from quality and compliance manager, during which incident processing form will be discussed and completed as well as a refresher training of RMBHS' medication policy and procedures prior to the start of the staff member's next shift with clients. Additionally, the staff member will receive managerial oversight during supervision of self-administration of medication for their next 2 shifts with clients to ensure understanding of and adherence to policy and procedures..." 6. A review of facility documentation revealed a document titled "Arizona Health Care Cost Containment System... INCIDENT, ACCIDENT OR DEATH REPORT" dated in May 2024. The IAD stated, "Medication: Guanfacine 1 mg - Take one tablet by mouth 2 times a day at noon and after school for impulsivity... [May 2024], at 3:38 pm [R6] self-administered [R6's] after school dose of guanfacine led by [E8]. At this time, Staff observed that the noon dosage was missed and contacted Weekend Manager [E10] and was instructed to contact poison control. Staff reached poison control at 4pm and spoke to [poison control representative] who reassured them that misses [sic] doses were common and advised to continue with normal dosing the following day at noon. Staff updated the Manager and was advised to contact the client's guardian. At 4:39 pm staff [sic] to [R6's guardian] and informed [R6's guardian] of the directions given by poison control. Guardian expressed no concerns at this time. Management then contacted Case Manager and informed them at 5:29pm. Management outreached to prescribing physician but was unable to make contact on [May 2024]. Further follow up with prescribing physician will occur on [May 2024]... INCIDENT TYPE: Safety/Risk Management... WITNESSES... [E8 and E4]... ACTION TAKEN AND/OR RECOMMENDED... Staff followed policies and procedures by contacting manager, poison control, guardian, prescribing physician, and case manager. Actions to be taken to reduce risk of similar errors in the future will be for staff member responsible to receive 1:1 oversight prior to next shift, during which an incident processing form will be discussed and completed as well as a refresher training of RMBHS' medication policy and procedures prior to the start of the staff member's next shift with clients. Additionally, the staff member will receive managerial oversight during supervision of self-administration of medication for their next 2 shifts with clients to ensure understanding and future adherence to policy and procedures... CLINICAL DIRECTOR REVIEW... Staff followed policies and procedures by informing manager upon recognition of medication error. Manager followed RMBHS Policy and Procedures by contacting program director, poison control, guardian, prescribing physician, and case manager. Staff member, [E8], will receive 1:1 clinical oversight during which incident processing form will be discussed and completed as well as a refresher training of RMBHS' medication policy and procedures prior to the start of the staff member's next shift with clients. Additionally, the staff member will receive managerial oversight during supervision of self-administration of medication for their next 2 shifts with clients to ensure understanding of and adherence to policy and procedures. Staff, [E8], will be put on a performance improvement plan indicating expectations." 7. In an exit interview, E1, O1, and O3 reviewed the findings and no additional documentation was provided.


summary: Compliance (Annual) - 2/21/2024

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on February 21, 2024:

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

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

findings: 1. A review of E2's personnel record revealed a TB skin test dated in December 2023. However, documentation of second TB skin test and a TB baseline screening was not available for review. 2. In an interview, E4 acknowledged documentation of evidence of freedom from infectious TB, as specified in R9-10-113(A)(2)(a)(i-iii) was not available for review. Technical Assistance was provided on this Rule during the compliance inspection conducted on February 13, 2023.

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

evidence: Based on observation and interview, the administrator failed to ensure a food menu was conspicuously posted at least one calendar day before the first meal on the food menu would be served. The deficient practice posed a risk if the dietary guidelines were not followed.

findings: 1. The Compliance Officer observed a current food menu was not conspicuously posted. 2. In an interview, E4 acknowledged the food menu was not conspicuously posted. Technical Assistance was provided on this Rule during the compliance inspection completed on February 13, 2023.


facility_name: YOUTH DEVELOPMENT INSTITUTE - PORTLAND HOUSE I I

summary: Complaint - 10/16/2024

raw_content: An on-site investigation of complaint AZ00212933 was conducted on October 16, 2024 and the following deficiencies were cited:

rule: M. An administrator shall ensure that the following information or documents are conspicuously posted on the premises and are available upon request to a personnel member, employee, resident, or a resident's representative: 1. The behavioral health residential facility's current license,

evidence: Based on observation, documentation review and interview, the administrator failed to ensure the behavioral health residential facility's current license was conspicuously posted and available upon request to a personnel member, employee, resident or a resident's representative. The deficient practice posed a risk as the Department was unable to ensure the facility's compliance.

findings: 1. The Compliance Officer observed the facility's license was not conspicuously posted on the premises or available upon request. 2. In an interview, E2 stated "it's posted in the front office" of the administration building. E1 and E2 acknowledged the facility's license was not conspicuously posted on the premises.

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

evidence: Based on documentation review and interview, the administrator failed to ensure there was a daily staffing schedule required per R9-10-706(K). The deficient practice posed a risk if there was no record to ensure shifts and tasks were covered.

findings: 1. The Compliance Officer requested the facility's daily staffing schedule but the schedule was not available. 2. In an interview, E4 reported the facility did not have staff scheduled due to having no residents at the facility. 3. In a joint interview, E1 and E2 acknowledged there was no daily staffing schedule maintained per R9-10-706(K).

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

findings: A.R.S. \'a7 36-401(23) "Health care institution" means every place, institution, building or agency, whether organized for profit or not, that provides facilities with medical services, nursing services, behavioral health services, health screening services, other health-related services, supervisory care services, personal care services or directed care services and includes home health agencies as defined in section 36-151, outdoor behavioral health care programs and hospice service agencies. A.R.S. \'a7 36-422(D) If a current licensee intends to terminate the operation of a licensed health care institution or if a change of ownership is planned, the current licensee shall notify the director in writing at least thirty days before the termination of operation or change in ownership is to take place. The current licensee is responsible for preventing any interruption of services required to sustain the life, health and safety of the patients or residents. A new owner shall not begin operating the health care institution until the director issues a license to the new owner. 1. A review of Department documentation revealed the behavioral health residential facility's perpetual license (BH3760) was effective on 2. In an interview, E4 stated "The last date of residents was on March 27, 2020." 3. In a joint interview, E1 and E2 reported the facility has been closed but does not want to close the facility license.

rule: A. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 4. A registered dietitian is employed full-time, part-time, or as a consultant; and

evidence: Based on record review and interview, the administrator failed to ensure a registered dietitian (RD) was employed full-time, part-time, or as a consultant. The deficient practice posed a risk if a resident's nutritional needs were not met.

findings: 1. A review of E5's personnel record revealed a contract to provide dietary services, however, the contract did not indicate E5 provided dietary services to the facility license BH3760. 2. In a joint interview, E1 and E2 acknowledged E5 was not employed full-time, part-time, or as a consultant for the facility.


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

raw_content: Based on Arizona Revised Statutes \'a7 36-424(B) and Arizona Administrative Code R9-10-109(E), the Department may accept an accreditation report in lieu of an onsite compliance inspection during the time of the accreditation report. The director may not accept an accrediation report in lieu of a complinace inspection of a health care institution if the health care institution has been subject to an enforcement action pursuant to section 36-427 or 36-431.01 within the year preceding the annual licensing fee anniversary date. The licensee submitted to the Department the current accreditation report from The Joint Commision, valid from April 3, 2021 through April 3, 2024. If the health care institution's accreditation report is not valid for the entire licensure period, the Department may conduct a compliance inspection of the health care institution during the time period the department does not have a valid accreditation report for the health care institution.


facility_name: R M B H S VINCENT HOUSE

summary: Compliance (Annual) - 10/22/2025

raw_content: An on-site compliance inspection was attempted on October 15, 2025, and no deficiencies were found during the on-site compliance inspection conducted on October 22, 2025.


summary: Compliance (Annual) - 10/2/2024

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

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

findings: R9-10-113(A)(2)(a)(i-ii)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 1. A review of E1's, E2's, E3's and E4's personnel record revealed a current negative TB skin test . However, documentation of TB baseline screening to include assessing risks of prior exposure to infectious tuberculosis, and determining if the individuals had signs or symptoms of tuberculosis was not available for review. 2. In a joint interview, E1 and E7 acknowledged E1, E2, E3 and E4 documentation of evidence of freedom from infectious TB, as specified in R9-10-113(A)(2)(a)(i-ii) was not available for review.

rule: B. An administrator shall ensure that: 1. A behavioral health residential facility has a: a. Room that provides privacy for a resident to receive treatment or visitors; and

evidence: Based on observation and interview, the administrator failed to ensure the behavioral health residential facility had a room to provide privacy for a resident to receive treatment or visitors. The deficient practice posed a risk if the administrator was unable to ensure confidentiality in treatment as well as a resident's right to privacy in treatment and visitation.

findings: 1. The Compliance Officers observed the facility did not have a room to provide privacy for a resident to receive treatment or for visitors. The Compliance Officers observed a room was designated to be the privacy room, however, the room was occupied by three beds. 2. In a joint interview, E1 and E6 acknowledged the facility did not have a room to provide privacy for a resident to receive treatment or visitors.

rule: B. An administrator shall ensure that: 8. A resident bedroom complies with the following: b. Is not used as a passageway to another bedroom or bathroom unless the bathroom is for the exclusive use of an individual occupying the bedroom;

evidence: Based on observation and interview, the administrator failed to ensure a resident bedroom was not used as a passageway to another bedroom or bathroom. The deficient practice posed a possible resident rights violation.

findings: 1. The Compliance Officer observed a bedroom across from stairs, which included two single beds. The bedroom contained a locked walk in closet that contained: multiple televisions, multiple computer screens, art decorations, and random house hold items. 2. In an interview, E1 reported the closet was used as storage for facilities belongings. 3. In a joint interview, E1 and E6 acknowledged the administrator failed to ensure a resident bedroom was not used as a passageway to another bedroom or bathroom.


summary: Compliance (Annual) - 9/26/2023

raw_content: The following deficiency was found during the on-site compliance inspection conducted on September 26, 2023:

rule: B. An administrator shall ensure that: 8. A resident bedroom complies with the following: g. Is a: ii. Shared bedroom that: (2) Except as provided in subsection (C), contains at least 60 square feet of floor space, not including a closet, for each individual occupying the shared bedroom; and

evidence: Based on observation and interview, the administrator failed to ensure a shared resident bedroom contained at least 60 square feet of floor space, not including a closet, for each individual occupying the shared bedroom.

findings: 1. The Compliance Officer observed three beds in a bedroom located on the first floor of the facility, directly across from the living room. Using an electronic measuring device, the Compliance Officer measured the bedroom to be 179 square feet. 2. In an interview, E1 acknowledged the bedroom did not contain at least 60 square feet of floor space for each individual occupying the bedroom.


facility_name: ZAREPHATH, INC

summary: Compliance (Annual) - 6/25/2025

raw_content: No deficiencies were found during the on-site compliance inspection conducted on June 25, 2025.


summary: Compliance (Annual) - 3/20/2024

raw_content: No deficiencies were found during the on-site compliance inspection conducted on March 20, 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: Compliance (Annual) - 11/14/2025

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


summary: Change of Service - 3/26/2025


summary: Compliance (Annual) - 10/22/2024

raw_content: No deficiencies were found during the on-site compliance inspection conducted on October 22, 2024.


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

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


summary: Complaint - 7/24/2024 - 8/2/2024

raw_content: An on-site investigation of complaint AZ00213526 was conducted on July 24, 2024 and August 2, 2024, and the following deficiencies were cited :

rule: C. An administrator shall ensure that: 2. Policies and procedures for behavioral health services and physical health services are established, documented, and implemented to protect the health and safety of a resident that: l. Cover resident outings;

evidence: Based on record review, documentation review, and interview the administrator failed to ensure policies and procedures which covered resident outings were implemented to protect the health and safety of a resident. This deficient practice posed a health and safety risk to residents. 1. A review of facility policies and procedures revealed a policy titled, "Policy 713: Outings" which stated, "It is the policy of Zarephath for staff to plan, prepare, document, and conduct outings in a manner that ensures the health, safety and welfare of each client ..." The policy then outlined the rules and documentation requirements for an outing in A.A.C. R9-10-713.A.-B. 2. A review of R1's medical record revealed progress notes from June 15, 2024. The notes contained a section titled "Assessment" which stated, "Client was taken to Brandi Fenton Park for splash pad ...Client then left splash pad and played on playscape. Client slid down slide and reported that slide was very hot. Peer reported that client had a burn and skin was peeling. Staff checked in on client and client reviewed that she had two burn marks on both sides of her posterior. The marks appeared to be about 4 inches in diameter and bright red. Client reported some skin peeling, stated that it hurt, but was not that bad. Client was asked to change to offer more protection..." 3. A review of facility documentation revealed "Meeting Agenda" notes from all staff meetings conducted on July 19, 26, 28, and August 2, 2024. The notes all stated, "Weekend Reminders: Repetition is the mother of Retention. This meeting agenda needs to be reviewed by all staff at the start of their shift." Each weekly meeting agenda also contained a section titled "Sun safety/ Swimming" which stated, "No groups are allowed to play on playground equipment when it is 100\'b0F or hotter. This will be a new policy moving forward and is effective immediately ..." 4. In an interview, E3 acknowledged R1 was burned on playground equipment during an outing. E3 reported staff allowed R1 to use the playground slide since it had a shade cover, but acknowledged the health and safety of a resident was not protected as required by rule and by the facility's outing policy. 5. In an interview, E6 acknowledged R1 was injured on an outing. E6 reported the facility updated its training on outings and conducted weekly meetings with staff to ensure residents remain safe on summer outings. E6 acknowledged the facility's policy which covered outings was not implemented to protect the health and safety of a resident.

rule: K. An administrator shall: 5. Establish and document the process for responding to a resident's need for immediate and unscheduled behavioral health services or physical health services;

evidence: Based on record review, documentation review, and interview, the administrator failed to establish and document the process for responding to a resident's need for immediate and unscheduled physical health services. The deficient practice posed a risk if the employees were unable to implement a procedure for responding to a resident's need for immediate and unscheduled physical health services.

findings: 1. A review of R1's medical record revealed progress notes from June 15, 2024. The notes contained a section titled "Assessment" which stated, "Client was taken to Brandi Fenton Park for splash pad ...Client then left splash pad and played on playscape. Client slid down slide and reported that slide was very hot. Peer reported that client had a burn and skin was peeling. Staff checked in on client and client reviewed that she had two burn marks on both sides of her posterior. The marks appeared to be about 4 inches in diameter and bright red. Client reported some skin peeling, stated that it hurt, but was not that bad. Client was asked to change to offer more protection. On call supervisor was called and then guardian was updated. Staff informed guardian that client had came down the slide and received two bright red burn marks on her lower posterior. Staff reviewed that client did not report much pain, but stated that it hurt. Staff also reviewed that it was peeling, Staff reviewed that due to where it is located, staff cannot fully check as marks are just inside bathing suit area. Staff had guardian talk with client over the phone to check in with client. Guardian talked with client and stated that it was ok for client to stay at respite. Guardian asked that staff monitor triple antibiotic ointment as well as gauze for client after client showers. Staff agreed ..." 2. A review of facility policies and procedures revealed no policy which established and documented the process for responding to a resident's need for immediate and unscheduled physical health services. 3. In an interview, E6 reported staff receive training on responding to residents' unscheduled physical health needs. E6 reported staff are trained to call the resident's guardian before any action is taken. E6 reported staff called R1's guardian when R1 was injured on June 15, 2024 and followed R1's guardian's directions. E6 acknowledged this process was not formalized in the facility's policies and procedures, and that the administrator failed to establish and document the process for responding to a resident's need for immediate and unscheduled physical health services.


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

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on April 15, 2024:

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

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

findings: 1. The Compliance Officer observed grab bars attached to the shower walls in two common bathrooms in the facility. 2. A review of R2's medical record revealed a treatment plan (dated October 2023.) The treatment plan stated under "Client Risk Factors" R2 had a "history of homicidal ideation, hurting animals, and has expressed feelings of not feeling safe in any environment." 3. In an interview, E1 reported R2's history was not current. E1 acknowledged the grab bars attached to the shower walls in two common bathrooms in the facility could potentially pose a risk to the health and safety of residents.


summary: Other - 8/21/2023

raw_content: No deficiencies were found during the off-site inspection to modify the floor plan to remove one bedroom and to add a privacy room on August 21, 2023.

inspection_type: Other


facility_name: DEVEREUX ARIZONA - CASA AMISTAD

summary: Compliance (Annual) - 8/13/2024

raw_content: Based on Arizona Revised Statutes \'a7 36-424(B) and Arizona Administrative Code R9-10-109(E), the Department may accept an accreditation report in lieu of an onsite compliance inspection during the time of the accreditation report. The director may not accept an accreditation report in lieu of a compliance inspection of a health care institution if the health care institution has been subject to an enforcement action pursuant to section 36-427 or 36-431.01 within the year preceding the annual licensing fee anniversary date. The licensee submitted to the Department the current accreditation report from The Joint Commission, valid from November 5, 2023, through November 5, 2025. If the health care institution's accreditation report is not valid for the entire licensure period, the Department may conduct a compliance inspection of the health care institution during the time period the department does not have a valid accreditation report for the health care institution.


summary: Compliance (Annual) - 8/25/2023

raw_content: Based on Arizona Revised Statutes, \'a736-424(B) and Arizona Administrative Code, R9-10-109(E), the Department may not conduct an onsite compliance inspection during the time of the accreditation report. The licensee submitted to the Department the current accreditation report from The Joint Commission, valid from November 5, 2023 through November 5, 2025. If the health care institution's accreditation report is not valid for the entire licensing fee period of August 1, 2023 through July 31, 2024, the Department may conduct a compliance inspection of the health care institution during the time period the department does not have a valid accreditation report for the health care institution.


summary: Compliance (Annual) - 4/14/2023

raw_content: Based on Arizona Revised Statutes, \'a736-424(B) and Arizona Administrative Code, R9-10-109(E), the Department may not conduct an onsite compliance inspection during the time of the accreditation report. The licensee submitted to the Department the current accreditation report from The Joint Commission, valid from November 5, 2023 through November 5, 2025. If the health care institution's accreditation report is not valid for the entire licensing fee period of August 1, 2022 through July 31, 2023, the Department may conduct a compliance inspection of the health care institution during the time period the department does not have a valid accreditation report for the health care institution.


facility_name: NEW HOPE OF ARIZONA, INCORPORATED

summary: Compliance (Annual) - 2/19/2026

raw_content: No deficiencies were found during the on-site compliance inspection conducted on February 19, 2026.


summary: Compliance (Annual) - 2/10/2025

raw_content: No deficiencies were found during the on-site compliance inspection conducted on February 10, 2025.


summary: Compliance (Annual) - 2/13/2024

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on February 13, 2024:

rule: A. An administrator shall ensure that: 5. Behavioral health services listed in the behavioral health residential facility's scope of services are provided on the premises;

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure behavioral health services listed in the behavioral health residential facility's scope of services were provided on the premises for one of two residents sampled. The deficient practice posed a risk if the residents admitted to the residential facility did not receive the behavioral health services expected to be provided on the premises.

findings: 1. A review of the facility policies and procedures revealed a scope of services. The scope of services stated, "...Behavioral Health Residential Services provides a structured treatment setting with twenty four hour supervision and counseling..." 2. A review of R1's treatment plan revealed no evidence counseling was provided to R1. 3. In an interview, E1 reported the identified facility resident receive respite services. E1 acknowledged the facility is licensed as a behavioral health residential facility. E1 acknowledged the behavioral health services listed in the behavioral health residential facility's scope of services was not provided on the premises for R1.


summary: Compliance (Annual) - 10/3/2025

raw_content: No deficiencies were found during the on-site compliance inspection conducted on October 3, 2025.


summary: Compliance (Annual) - 9/19/2024

raw_content: No deficiencies were found during the on-site compliance inspection conducted on September 19, 2024.


facility_name: ANIMALS FACILITATING ADOLESCENTS AND CHILDREN

summary: Compliance (Annual) - 1/15/2026

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on January 15, 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 or admitted to the health care institution had an assessment of risks of prior exposure to infectious tuberculosis (TB), and determining if the individual had signs or symptoms of tuberculosis for four of six 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 R1's medical record revealed no documentation of a TB risk assessment or signs and symptoms of TB. 2. A review of E1, E3, and E4’s personnel records revealed no documentation of a TB risk assessment or signs and symptoms of TB. 3. In an interview, E1 reported E1 was unable to locate documentation of a TB risk assessment or signs and symptoms of TB within R1, E1, E3, or E4’s records. 4. In an exit interview, the findings were reviewed with E1, and no further documentation or comment was provided.

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 three 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 E1, E3, and E4's personnel records 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 E1, E3, and E4. 2. In an interview, E1 reported being unaware of the requirement for a DCS central registry background check. 3. In an exit interview, the findings were reviewed with E1, and no further documentation or comment was provided.


summary: Compliance (Annual) - 1/6/2025

raw_content: No deficiencies were found during the on-site compliance inspection conducted on January 6, 2025.


summary: Compliance (Annual) - 1/9/2024

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on January 9, 2024:

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

findings: 1. The Compliance Officer observed a bathroom in the facility with a grab bar attached to the wall, next to the shower. The Compliance Officer observed an unsecured steak knife in the dish basket in the kitchen. 2. A review of R2's medical record revealed R2 had self-harming behaviors under "Summary of Issues Identified" in R2's initial psychosocial assessment. 3. In an interview, E1 acknowledged the grab bar in the bathroom and the unsecured steak knife. E1 reported knives are always locked up. However, E1 had forgotten to secure the knife on the day of the inspection. E1 acknowledged the potential risk to the physical health and safety of residents.


summary: Change of Service - 11/14/2023

raw_content: No deficiencies were found during the off-site inspection to decrease the occupancy from eight to five, conducted on November 14, 2023.


facility_name: DEVEREUX ARIZONA - CASA ENSUENO

summary: Compliance (Annual) - 8/13/2024

raw_content: Based on Arizona Revised Statutes \'a7 36-424(B) and Arizona Administrative Code R9-10-109(E), the Department may accept an accreditation report in lieu of an onsite compliance inspection during the time of the accreditation report. The director may not accept an accreditation report in lieu of a compliance inspection of a health care institution if the health care institution has been subject to an enforcement action pursuant to section 36-427 or 36-431.01 within the year preceding the annual licensing fee anniversary date. The licensee submitted to the Department the current accreditation report from The Joint Commission, valid from November 5, 2023, to November 5, 2025. If the health care institution's accreditation report is not valid for the entire licensure period, the Department may conduct a compliance inspection of the health care institution during the time period the department does not have a valid accreditation report for the health care institution.


summary: Complaint - 1/18/2024

raw_content: An on-site investigation of complaint AZ00195653 was conducted on January 18, 2024 and the following deficiency was cited :

rule: B. An administrator shall ensure that counseling is: 1. Offered as described in the behavioral health residential facility's scope of services, 2. Provided according to the frequency and number of hours identified in the resident's treatment plan, and 3. Provided by a behavioral health professional or a behavioral health technician.

evidence: Based on documentation review, record review and interview, the administrator failed to ensure the facility's scope of services included a description of how counseling would be offered, and treatment plans included the frequency and number of hours counseling was to be provided, for three of three residents sampled. The deficient practice posed a risk if a resident did not receive treatment to cure, improve, or palliate their behavioral health issue at the health care institution.

findings: A.A.C. R9-10-101(36) states, " 36. "Behavioral health residential facility" means a health care institution that provides treatment to an individual experiencing a behavioral health issue that: a. Limits the individual's ability to be independent, or b. Causes the individual to require treatment to maintain or enhance independence." A.A.C. R9-10-101(238) states, "238. "Treatment" means a procedure or method to cure, improve, or palliate an individual's medical condition or behavioral health issue." A.A.C. R9-10-101(200) states, " 200. "Respite services" means respite care services provided to an individual who is receiving behavioral health services." 1. A review of facility documentation revealed an undated policy and procedure titled "Program Model: Facility Based Respite" dated October 20, 2022. The policy and procedure stated, "Purpose Devereux Arizona is committed to providing the least restrictive and most appropriate services to individuals referred for care. Facility Based Respite care is designed to provide short-term relief to primary caregivers (parents/guardians) of children with developmental, emotional, or behavioral needs. Respite is neither a level of care nor a therapeutic/ treatment based intervention. It is a formal, structured "break" for families. All Respite requests will be made with as much prior notice as possible, but no less than 24 hours. Respite care is not a substitute for crisis intervention/ stabilization, hospitalization, or residential treatment. Program Objectives The Respite Program focuses on providing safe and temporary home environments for children, while giving families and children a much needed "break". These regularly scheduled breaks are intended to proactively preserve the family unit, and help dissolve the need for out-of-home placement at a later time by giving the primary caregiver an opportunity to recuperate and re-charge. In this way, the primary caregiver will then be better prepared to effectively parent the child despite the challenges and stressors presented by the child and his/her behavioral health condition. All parents and caregivers need and benefit from a break from their parental duties at times, and the need for these breaks is exacerbated when raising a child or adolescent with behavioral health challenges. Devereux understands that in order for respite to serve its purpose successfully. Respite staff must be equipped with knowledge and support, and individual's individual strengths and challenges must be carefully assessed when arranging respite." However, the scope of services did not include a description of how counseling would be offered. 2. In an interview, E1 reported the aforementioned policy and procedure was the facility's scope of services. 3. A review of R1's, R2's and R3's treatment plans revealed R1's, R2's and R3's treatment plans did not include the frequency and number of hours counseling was to be provided to R1, R2, and R3. 4. The Compliance Officer requested to review counseling notes for R1, R2, and R3 however, counseling notes for R1, R2, and R3 were not available for review. 5. In an interview, E2 reported the facility provides medication administration and behavioral management. E2 reported staff monitor behaviors on shift notes. E2 reported the facility does not provide treatment such as group counseling or individual counseling. 6. In a joint interview, E1, E2, and E3 reported the facility is a respite-only facility and operates on the weekends. E1, E2, and E3 acknowledged the scope of services did not include a description of how treatment such as counseling would be offered, and R1's, R2's and R3's treatment plans did not include the frequency and number of hours of treatment such as counseling was to be provided R1, R2, and R3.