AMERICAN CARE HOMES, INC

INSP-0130961

Complete

Date: 5/7/2025

Type: Complaint;Compliance (Annual)

Worksheet: Behavioral Health Residential Facility

SOD Sent: 2025-05-22

Summary:

The following deficiencies were found during the on-site investigation of complaint 129792 and compliance inspection conducted on May 7, 2025.

Deficiencies Found: 6

Deficiency #1

Rule/Regulation Violated:

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

Evidence/Findings:

Based on the record review and interview, the administrator failed to ensure that personnel records were maintained throughout an individual’s period of providing services in or for the behavioral health residential facility, for three of the five personnel sampled. The deficient practice posed a risk as the Department was unable to verify the required information. Findings include: R9-10-706(G)(1-3) states: “G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes:1. The individual’s name, date of birth, and contact telephone number;2. The individual’s starting date of employment or volunteer service and, if applicable, the ending date; and3. Documentation of:a. The individual’s qualifications, including skills and knowledge applicable to the individual’s job duties;b. The individual’s education and experience applicable to the individual’s job duties;c. The individual’s completed orientation and in-service education as required by policies and procedures;d. The individual’s license or certification, if the individual is required to be licensed or certified in this Article or policies and procedures;e. The individual’s compliance with requirements in A.R.S. §§ 36-411, 36-411.01, and 36-425.03, as applicable;f. The individual’s compliance with the requirements in A.R.S. § 8-804, if applicable;g. If the individual is a behavioral health technician, clinical oversight required in R9-10-115;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; andj. Evidence of freedom from infectious tuberculosis, if required for the individual according to subsection (F).” 1. A review of E2’s (hired in 2024 as a behavioral health technician) personnel record revealed documentation of compliance with R9-10-706(G)(3)(e) and R9-10-706(G)(3)(h-i). However, documentation of compliance with R9-10-706(G)(1-2), R9-10-706(G)(3)(a-c), and R9-10-706(G)(3)(j) was not available for review. 2. A review of E3’s (hired in 2024 as a behavioral health technician) personnel record revealed documentation of compliance with R9-10-706(G)(3)(e). However, documentation of compliance with R9-10-706(G)(1-2), R9-10-706(G)(3)(a-c), R9-10-706(G)(3)(h-i), and R9-10-706(G)(3)(j) was not available for review. 3. A review of E4’s (hired in 2024 as a behavioral health professional) personnel record revealed documentation of compliance with R9-10-706(G)(3)(e), R9-10-706(G)(3)(d), and R9-10-706(G)(3)(g-h). However, documentation of compliance with R9-10-706(G)(1-2), R9-10-706(G)(3)(a-c), and R9-10-706(G)(3)(j) was not available for review. 4. In an interview, E1 reported E2, E3, and E4 have the aforementioned documents maintained in their personnel records, however, E1 could not locate the documentation. E1 acknowledged the personnel records for E2, E3, and E4 were not maintained. 5. In an exit interview, the findings were reviewed with E1, and no additional comments or statements were provided regarding the findings.

Temporary Solution:

The Administrator immediately reviewed all current personnel files to identify missing documentation. Missing documents for E2, E3, and E4 were obtained (copies of IDs, qualifications, training certificates, and TB test results) and placed in their personnel files. No staff are permitted to work until their files are complete and verified.

Permanent Solution:

A Personnel File Checklist was created and implemented for all new hires and current staff. The Administrator (or designee) will ensure all required documentation under R9-10-706(G)(1–3) is collected and verified before an employee begins providing services. Personnel files will be maintained in a locked, organized system (physical or digital) accessible only to authorized administrative staff.

Person Responsible:

Kaitlan Taylor, Admin

Deficiency #2

Rule/Regulation Violated:

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

Evidence/Findings:

Based on documentation review, record review, and interview, the administrator failed to ensure a resident's medical record contained orders for one of two residents sampled. The deficient practice posed a risk as the Department was unable to verify the required information. Findings include: 1. A review of R2’s medical record revealed a medication administration record (MAR) for May 2025. The MAR revealed R2 was provided the following medications on the following dates and times:-”Olanzapine 10 mg” on May 1-6, 2025 at 8:00 PM; and-”Clonidine HCL 600 mg” on May 1-7, 2025 at 8:00 AM. 2. A review of R2's medical record revealed medication orders dated February 20, 2025. However, the medication orders did not include ”Olanzapine 10 mg” and ”Clonidine HCL 600 mg” 3. In an interview, E2 reported that R2 was provided the aforementioned medications; however, E2 could not locate the medication orders. E2 clarified R2 was provided with “Clonidine HCL 0.1 mg”, and R2’s MAR incorrectly indicated R2 was provided “Clonidine HCL 600 mg.” 4. In an interview, E1 acknowledged the medication orders for the aforementioned medications were not in R1’s medical record. 5. In an exit interview, the findings were reviewed with E1, and no additional comments or statements were provided regarding the findings.

Temporary Solution:

The Administrator immediately reviewed all current residents’ MARs and corresponding physician orders. Missing or incomplete orders were obtained from prescribing providers and filed in residents’ charts. The MAR for R2 was corrected to accurately reflect prescribed medications and dosages. Staff were retrained on verifying orders prior to medication administration.

Permanent Solution:

A new Medication Order Verification Procedure was implemented requiring staff to:
Verify a written or electronic physician order is on file before adding a medication to the MAR.
Ensure any medication changes are supported by updated provider orders.
The Administrator or Nurse will review all MARs and orders weekly to confirm accuracy and completeness.

Person Responsible:

Kaitlan Taylor, President/CEO/Admin

Deficiency #3

Rule/Regulation Violated:

R9-10-716.A.7.a. Behavioral Health Services A. An administrator shall ensure that: 7. A resident does not: a. Use or have access to any materials, furnishings, or equipment or participate in any activity or treatment that may present a threat to the resident's health or safety based on the resident's documented diagnosis, treatment needs, developmental levels, social skills, verbal skills, or personal history; or

Evidence/Findings:

Based on observation, record review, and interview, the administrator failed to ensure a resident did not have access to any materials which presented a threat to the resident's health or safety based on the resident's documented diagnosis, or personal history. The deficient practice posed a risk as a resident had access to materials while admitted into a behavioral health residential facility. Findings include: 1. A review of facility documentation revealed an incident report dated February 17, 2025. The incident report stated “THE CLIENT WAS OUTSIDE WHEN [R1’s] house mates saw [R1] shaking as though [R1] was having a seizures [sic]. [R1] WAS SITTED [sic] ON ONE OF THE CHAIRS OUTSIDE. WHEN THEY CALLED ME I FOUND [R1] UNRESPONSIVE BUT BREATHING. I CALLED 911, THEY CAME AND DID A [sic] ASSESSMENT. THEY ADMINISTERED [R1] WITH NARCAN FOR OD.” 2. A review of facility documentation revealed a document titled “Shift Summary” dated March 3, 2025. The document stated “[R1’s] face looked red [R1’s] right eye appear red and shinny [sic] and a little bit swollen…[R1’s] speedy [sic] and reactions were slow, [R1] was unsettled and could barely sit down…We did a drug test and [R1] tested positive for met [sic], MDMA, and Amp. [R1] attested to taking drugs the previous day and night. [R1] has barely been [themself].” 3. A review of facility documentation revealed a document titled “Urine Test” dated March 3, 2025. The document stated “AMPHETAMINE (AMP) RESULT…POSITIVE…EXTACY [sic] (MDMA) RESULT…POSITIVE…METHAMPHETAMINE (MAMP) (MET) RESULT…POSITIVE”. 4. A review of R1’s medical record revealed a behavioral health assessment dated in February 2025. The assessment stated “[R1] is also diagnosed with other stimulant dependence. [R1] reports that [R1’s] drug of choice is methamphetamine…Diagnosis F33.3 Major depressive disorder, recurrent, severe with psychotic symptoms F15.20 Other stimulant dependence, uncomplicated.” 5. In an interview, E1 reported R1 brought the aforementioned substances into the facility upon admission to the facility and used the substances on the aforementioned dates. E1 reported R1 hid the aforementioned substances in the clothes worn by R1 upon admission. E1 acknowledged R1 had access to materials which may have presented a threat to R1’s health or safety based on R1’s documented diagnosis or personal history. 6. In an exit interview, the findings were reviewed with E1, and no additional comments or statements were provided regarding the findings.

Temporary Solution:

Immediately following the incident, staff conducted a full facility and room search to ensure no other contraband or unsafe materials were present. All residents were screened and monitored for signs of substance use. R1 was transported for medical evaluation, and upon return, placed on enhanced supervision. Staff were re-educated on admission search protocols and observation procedures.

Permanent Solution:

A revised Contraband and Safety Screening Policy was implemented requiring:
Comprehensive searches of all residents and belongings upon admission and after community outings, documented by two staff members.
Use of a Resident Belongings Checklist to document items cleared or confiscated.
Ongoing staff training on recognizing and managing contraband, substance use risk, and resident safety per R9-10-716(A)(7)(a).
Installation of secure storage areas for resident belongings and monitoring equipment in common areas.

Person Responsible:

Kaitlan Taylor, Admin

Deficiency #4

Rule/Regulation Violated:

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/Findings:

Based on the record review and interview, the administrator failed to ensure the assistance in the self-administration of medication provided to a resident was in compliance with an order for one of two residents sampled. The deficient practice posed a risk as assistance in the self-administration of medication could not be verified against a medication order. Findings include: 1. A review of R2's medical record revealed a medication order dated February 20, 2025, for “Abilify 5 mg PO QD”. 2. A review of R2’s medical record revealed a medication administration record (MAR) for May 2025. The MAR revealed there was no documentation to indicate R2 was provided “Abilify 5 mg”. 3. In an interview, E2 reported “Abilify 5 mg” is a discontinued medication, and R2 no longer takes the medication, however, E2 could not locate an updated medication order for R2. 4. In an exit interview, the findings were reviewed with E1, and no additional comments or statements were provided regarding the findings.

Temporary Solution:

All resident MARs and medication orders were immediately reviewed by the Administrator and Medication Staff. Missing or outdated orders were obtained from prescribing providers and updated in residents’ charts. R2’s record was corrected to reflect accurate medication status. Staff were retrained to verify current physician orders before providing medication assistance.

Permanent Solution:

A Medication Order Reconciliation Procedure was established requiring:
Verification of active orders upon admission, discharge, or medication change.
Immediate documentation of discontinued medications with corresponding provider orders.
Weekly review of all MARs against physician orders by the Administrator or Nurse to ensure compliance with R9-10-718(C)(6)(a).
Staff training incorporated into orientation and annual competency evaluations.

Person Responsible:

Kaitlan Taylor, Admin

Deficiency #5

Rule/Regulation Violated:

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/Findings:

Based on documentation review and interview, the administrator failed to ensure the equipment was free from a condition or situation that may cause a resident or other individual physical injury. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. The Compliance Officer observed a window in a hallway bathroom. The window was broken through the center and contained jagged glass. 2. In an interview, E1 acknowledged the hallway bathroom window was damaged, and the premises were not free from a condition or situation that may cause a resident or other individual to suffer physical injury. 3. In an exit interview, the findings were reviewed with E1, and no additional comments or statements were provided regarding the findings.

Temporary Solution:

The damaged window was immediately secured and covered to prevent access. Maintenance staff removed all jagged glass and installed a temporary protective barrier. Residents were restricted from using the affected bathroom until repairs were completed and the area was deemed safe.

Permanent Solution:

The window was replaced. A Facility Maintenance and Safety Inspection Protocol was updated to include daily visual safety checks by staff and monthly formal safety inspections by the Administrator or designee. All maintenance issues must now be documented on a Maintenance Work Order Log with goal dates of completion.

Person Responsible:

Kaitlan Taylor, Admin

Deficiency #6

Rule/Regulation Violated:

R9-10-722.B.8.e. Physical Plant Standards B. An administrator shall ensure that: 8. A resident bedroom complies with the following: e. Has window or door covers that provide resident privacy;

Evidence/Findings:

Based on observation and interview, the administrator failed to ensure a resident’s bedroom had window or door covers that provide resident privacy. Findings include: 1. The Compliance Officer observed a bedroom shared by R3 and R4. The bedroom contained a door leading to the hallway. The door contained a window and did not provide privacy to the residents. 2. In an interview, E1 reported the bedroom door window had a covering, however, R3 and R4 removed the covering. E1 acknowledged the bedroom door in R3’s and R4’s bedroom did not provide privacy. 3. In an exit interview, the findings were reviewed with E1, and no additional comments or statements were provided regarding the findings.

Temporary Solution:

A temporary privacy covering (opaque film and curtain) was immediately installed on the door window in R3 and R4’s bedroom. Staff confirmed all resident bedrooms had appropriate window or door coverings to maintain privacy. Residents were reminded not to remove or damage privacy coverings.

Permanent Solution:

Installed permanent board on all bedroom door windows to prevent removal while maintaining light and safety visibility. Meeting was held to discuss updating the Resident Room Privacy protocol to include procedures for maintaining privacy coverings and documenting any damage or removal by residents. Staff were retrained to perform daily room checks to ensure privacy compliance.

Person Responsible:

Kaitlan Taylor, Admin

INSP-0058726

Complete

Date: 2/3/2025

Type: Complaint

Worksheet: Behavioral Health Residential Facility

SOD Sent: 2025-02-12

Summary:

An on-site investigation of complaint AZ00222239 was conducted on February 3, 2025 and the following deficiency was cited :

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

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

Evidence/Findings:

Based on observation and interview, the registered dietician failed to ensure that meals and snacks provided by the behavioral health residential facility were serviced according to posted menus.

Findings include:

1. The Compliance Officer observed a menu posted on the refrigerator in the kitchen. The menu indicated the meal for Supper was "Soup of the Day, Crispy Chicken Tenders, Tossed Salad/Dressing, Lemon Meringue Pie, Breadstick, Milk/Beverage". The menu indicated the "Evening Snack" was "Fruit Drink" and "Sandwich Half." However, the Compliance Officer did not see the items or ingredients for soup, lemon meringue pie, breadsticks, and sandwiches. The menu indicated E3 was the registered dietician.

2. In an interview, R2 reported the staff members of the facility go to the grocery store weekly. R2 "we cook the food ourselves and the staff helps if we need it. I ' m not really sure about the menu, if it's followed."

3. In an exit interview, E1 reported E1 was planning on going to the grocery store the following day.

INSP-0058724

Complete

Date: 8/15/2024

Type: Complaint;Compliance (Annual)

Worksheet: Behavioral Health Residential Facility

SOD Sent: 2024-09-26

Summary:

The following deficiencies were found during the on-site compliance inspection and investigation of complaint AZ00209516 conducted on August 15, 2024:

Deficiencies Found: 16

Deficiency #1

Rule/Regulation Violated:

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

Evidence/Findings:

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

Findings include:

1. A review of facility documentation revealed on August 1, 2020, the facility was licensed for a total capacity of five (5) residents.

2. A review of facility documentation revealed a fire department operating permit from the city of Phoenix with the description, "... Permit Type: Behavioral Health Facility; No of Licensed Beds or Person: 5..."

3. The Compliance Officer observed a door outside of the main facility which appeared to be a storage room in the backyard. The Compliance Officer requested the door to be opened. However, E5 reported E7 was the only person who had keys to the room. E5 reported the room was E7's bedroom.

4. In an interview, E5 reported E7 was a new caregiver/behavioral health technician for the facility.

5. In an interview, E5 acknowledged the health care institution failed to comply with A.R.S. \'a7 36-407(A).

Deficiency #2

Rule/Regulation Violated:

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

Evidence/Findings:

Based on documentation review, record review, and interview, the health care institution failed to develop and administer an initial training and continued competency training program in fall prevention and fall recovery. The deficient practice posed a risk to residents if personnel were unable to safely assist a resident during a fall.

Findings include:

1. A review of facility documentation revealed a policy and procedure titled, " Fall Prevention & Recovery.... 67.0 Fall Prevention and Fall Recovery Training."

2. A review of E2's personnel record revealed documentation of an initial training and continued competency training in fall prevention and fall recovery was not available for review.

3. A review of E3's personnel record revealed documentation of an initial training and continued competency training in fall prevention and fall recovery was not available for review.

4. A review of E6's personnel record revealed documentation of an initial training and continued competency training in fall prevention and fall recovery was not available for review.

5. In an interview, E5 acknowledged documentation of an initial and continued competency training in fall prevention and fall recovery was not available for review.

Deficiency #3

Rule/Regulation Violated:

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/Findings:

Based on record review and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of the individual's qualifications, including skills and knowledge applicable to the individual's job duties, for one of six personnel members sampled. The deficient practice posed a risk if a personnel member was unable to meet a resident's needs.

Findings include:

1. A review of E5's personnel record revealed documentation of E5's skills and knowledge was not available for review.

2. A review of E6's personnel record revealed documentation of E6's skills and knowledge was not available for review.

3. In an interview, E5 acknowledged documentation of E5's and E6's skills and knowledge was not maintained in the personnel record.

Deficiency #4

Rule/Regulation Violated:

G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes:
3. Documentation of:
b. The individual's education and experience applicable to the individual's job duties;

Evidence/Findings:

Based on record review and interview, the administrator failed to ensure documentation of an individuals education and experience was maintained in a personnel record, for one of six personnel records sampled. The deficient practice posed a risk if a personnel member was unable to meet a resident's needs.

Findings include:

1. A review of E6's personnel record revealed documentation of E6's education and experience was not available for review.

2. In an interview, E5 acknowledged documentation of E6's education and experience was not maintained in a personnel record.

Deficiency #5

Rule/Regulation Violated:

G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes:
3. Documentation of:
d. The individual's license or certification, if the individual is required to be licensed or certified in this Article or policies and procedures;

Evidence/Findings:

Based on record review and interview, the administrator failed to ensure documentation of an individuals license or certification was maintained in a personnel record.

Findings include:

1. A review of E4's personnel record revealed an expired registered dietician license dated September 1, 2022 to August 31, 2023. However, documentation of a current valid license was not available for review.

2. In an interview, E5 acknowledged the license on file was expired.

3. In an interview, E5 reported E4's license on file would be updated.

Deficiency #6

Rule/Regulation Violated:

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/Findings:

Based on record review and interview, the administrator failed to ensure a personnel record was maintained for each personnel member that included documentation of the individuals compliance with A.R.S. \'a7\'a7 36-411. The deficient practice posed a risk to the health and safety of residents if staff was unfit to work at the behavioral health facility.

Findings include:

1. A review of E2's personnel record revealed documentation of good faith efforts to contact previous employers was not available for review.

2. In an interview, E5 acknowledged required documentation was not maintained in E2's personnel record.

Deficiency #7

Rule/Regulation Violated:

G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes:
3. Documentation of:
j. Evidence of freedom from infectious tuberculosis, if required for the individual according to subsection (F).

Evidence/Findings:

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 evidence of freedom from infectious tuberculosis (TB), if required for the individual according to subsection (F). The deficient practice posed a TB exposure risk to residents.

Findings include:

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

1. A review of facility documentation revealed a policy titled, " Tuberculosis Screening." The policy stated, "... 3). Records: a). Documentation of the TB screening test of an individual hired by American Care Homes will be maintained at the facility in the employee file; b). Documentation of screening for signs or symptoms of TB of an individual will be maintained at the facility in the employees file..."

2. A review of E2's personnel record revealed documentation of a TB baseline screening consisting of assessing risks of prior exposure to infectious TB was not available for review.

3. A review of E3's personnel record revealed documentation of a TB baseline screening consisting of assessing risks of prior exposure to infectious TB was not available for review.

4. A review of E6's personnel record revealed documentation of freedom from infectious TB and baseline screening consisting of assessing risks of prior exposure to infectious TB was not available for review.

5. In an interview, E5 acknowledged personnel records did not contain current documentation of evidence of freedom from infectious TB.

Deficiency #8

Rule/Regulation Violated:

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

Evidence/Findings:

Based on record review and interview, the administrator failed to ensure documentation of evidence of freedom from infectious tuberculosis (TB) was maintained in a residents medical record. The deficient practice posed a risk to the health and safety of residents.

Findings include:

1. A review of R2's medical record revealed documentation of evidence from infectious TB, as specified in R9-10-113, was not available for review.

2. In an interview, E5 acknowledged documentation of evidence of freedom from infectious TB was not available in the residents medical record.

Deficiency #9

Rule/Regulation Violated:

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

Evidence/Findings:

Based on record review and interview, the administrator failed to ensure a resident medical record contained documented general consent and informed consent for treatment by the resident or residents representative. The deficient practice posed a risk to the health and safety of residents if residents did not consent to treatment.

Findings include:

1. A review of R2's medical record revealed documentation of informed consent for treatment was not available for review.

2. In an interview, E5 reported E5 did the intake paperwork for R2 but could not find the documentation.

Deficiency #10

Rule/Regulation Violated:

C. If a behavioral health residential facility provides assistance in the self-administration of medication, an administrator shall ensure that:
5. A personnel member, other than a medical practitioner or registered nurse, completes the training in subsection (C)(4) before the personnel member provides assistance in the self-administration of medication; and

Evidence/Findings:

Based on documentation review, record review, and interview, the behavioral health residential facility failed to ensure a personnel member completed the training in subsection (C)(4) before providing assistance in the self-administration of medication. The deficient practice posed a risk to health and safety of residents if staff were unqualified to assist during medication.

Findings include:

1. A review of facility documentation revealed a policy titled, " 7.0 Employee Personnel Records." The policy stated, "... 3. Personnel records will include documentation indicating the staff member is in compliance with the following... orientation and training verification..."

2. A review of E5's and E6's personnel record revealed documentation of training in assistance in the self-administration of medication was not available for review.

3. In an interview, E5 acknowledged documentation of a current training in assistance in the self-administration of medication was not available for review.

Deficiency #11

Rule/Regulation Violated:

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/Findings:

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 to the health and safety of residents if residents were unable to ensure nutritional needs and dietary restrictions.

Findings include:

1. The Compliance Officer observed several postings in the facility kitchen. However, a food menu was not conspicuously posted.

2. In an interview, E5 acknowledged the food menu was not conspicuously posted on the premises.

3. In an interview, E5 reported E5 was in the process of updating the menu to the current date.

Deficiency #12

Rule/Regulation Violated:

C. An administrator shall:
3. Maintain documentation of a current fire inspection.

Evidence/Findings:

Based on documentation review and interview, the administrator failed to ensure documentation of a current fire inspection was maintained. The deficient practice posed a risk to the health and safety of residents.

Findings include:

1. A review of facility documentation revealed a fire department operating permit issued February 15, 2023 and expired on February 14, 2024. However, documentation of a current fire inspection was not available for review.

2. In an interview, E5 reported the fire inspection was up to date but did not have the required documentation on-site.

Deficiency #13

Rule/Regulation Violated:

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/Findings:

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

Findings include:

1. The Compliance Officer observed an uncovered electrical outlet behind the residents bed in bedroom number three.

2. In an interview, E5 acknowledged a resident may suffer physical injury from the exposed electrical outlet.

3. In an interview, E5 reported the outlet will be replaced.

Deficiency #14

Rule/Regulation Violated:

A. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that:
10. Hot water temperatures are maintained between 95° F and 120° F in the areas of the behavioral health residential facility used by residents;

Evidence/Findings:

Based on observation and interview, the administrator failed to ensure hot water temperatures were maintained between 95\'b0 F and 120\'b0 F in the areas of the behavioral health residential facility used by residents.

Findings include:

1. The Compliance Officer observed the water temperature to be 127.9\'b0F in the kitchen of the facility, using a Department issued thermometer.

2. In an interview, E5 acknowledged the water temperature was outside of the accepted range. In an interview, E5 reported the water temperature will be adjusted.

Deficiency #15

Rule/Regulation Violated:

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

Evidence/Findings:

Based on observation and interview, the administrator failed to ensure poisonous or toxic materials stored by the behavioral health residential facility was maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and were inaccesible to residents. The deficient practice posed a risk to the health and safety of residents if chemicals were to contaminate food maintained in the same closet.

Findings include:

1. The Compliance Officer observed a closet near the front door of the facility which contained food and cleaning chemicals. The following items were observed:
- "Kirkland" jasmine rice, "Stokelys" kennel corn, "Double Q" pink salmon, "Del Monte" traditional spaghetti sauce, "Peak" lentils, "Columbia" spaghetti, "Besler" macaroni and cheese, "Great Value" coffee, "Bertolli" pasta sauce, and "Del Monte" cut green beans
- "Ecologic" bed bug killer, "Lysol" disinfectant spray, "Lysol" toilet bowl cleaner, "Lysol" all purpose cleaner, "Sprayway" glass cleaner, "Great Value" glass cleaner, "Febreeze" air mist, "Clorox" cleaner and bleach, "Kingsford" charcoal, and "Expert Grill" lighter fluid

2. In an interview, E5 acknowleged poisonous and toxic materials were stored with food. In an interview, E5 reported E5 would store the items separately.

Deficiency #16

Rule/Regulation Violated:

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

Evidence/Findings:

Based on documentation review, record review, and interview, the health care institution failed to implement Tuberculosis (TB) infection control activities that include providing annual training and education related to recognizing signs and symptoms of TB. The deficient practice posed a TB exposure risk to staff and residents.

Findings include:

1. A review of facility documentation revealed a policy and procedure titled, " Tuberculosis Screening." The policy stated, "... Training: Personnel and independent contractors will attend tuberculosis training prior to providing services and prior to hiring. Personnel and independent contractors will attend annual tuberculosis training to continue their education. The tuberculosis training will be mandatory training..."

2. A review of E1's, E2's, E3's, E5's, and E6's personnel records revealed documentation of a training in identifying signs and symptoms of tuberculosis was not available for review.

3. In an interview, E5 acknowledged the required annual TB signs and symptoms training was not available for review.

INSP-0058722

Complete

Date: 3/11/2024

Type: Complaint

Worksheet: Behavioral Health Residential Facility

SOD Sent: 2024-04-08

Summary:

An on-site investigation of complaint AZ00201766 was conducted on March 11, 2024 and the following deficiency was cited :

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

K. An administrator shall ensure that:
1. At least one personnel member is present and awake at the behavioral health residential facility when a resident is on the premises;

Evidence/Findings:

Based on documentation review and interview, the administrator failed to ensure at least one personnel member was present and awake at the behavioral health residential facility when a resident was on the premises. The deficient practice posed a risk to the health and safety of residents.

Findings include:

1. A review of facility documentation revealed a January 2023 staff schedule and February 2023 staff schedule. A review of the January 2023 staff schedule revealed one 24 hour shift. A review of the February 2023 staff schedule revealed one 24 hour shift.

2. A review of facility documentation revealed facility policies and procedures with the following section, " 14.0 Daily Staffing Schedule; Purpose: To ensure that the agency has sufficient staff members to provide resident supervision and treatment as well as to protect the health, safety, and welfare of all residents at all times, on the premises, on agency-sponsored activity off the premises and while the resident in receiving behavioral health services or ancillary serviced for the licensee off the premises..."

3. In an interview, E1 and E2 acknowledged the administrator failed to ensure at least one personnel member was present and awake at the behavioral health residential facility when a resident was on the premises.

INSP-0058720

Complete

Date: 7/13/2023

Type: Compliance (Annual)

Worksheet: Behavioral Health Residential Facility

SOD Sent: 2023-07-21

Summary:

The following deficiencies were found during the on-site compliance inspection conducted on July 13, 2023:

Deficiencies Found: 4

Deficiency #1

Rule/Regulation Violated:

G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes:
3. Documentation of:
g. If the individual is a behavioral health technician, clinical oversight required in R9-10-115;

Evidence/Findings:

Based on documentation review, record review, and interview, the administrator failed to ensure a personnel record was maintained for a behavioral health technician (BHT) to include documentation of clinical oversight, required in R9-10-115, for two of two BHTs sampled. The deficient practice posed a risk to the health and safety of residents if BHTs provided clinical services they were not licensed to provide without clinical oversight by a licensed behavioral health professional (BHP), and the Department was unable to determine substantial compliance during the inspection.

Findings include:

1. A review of facility documentation revealed a policy and procedure titled "Clinical Oversight Direct Supervision"(dated May 2022). The policy stated "A behavioral health technician will receive clinical oversight after providing behavioral health services such as assessment, treatment plan, counseling or if that behavioral health technician was involved in an incident."

2. A review of E2's and E3's personnel records revealed documentation of clinical oversight, required in R9-10-115, was not available for review.

3. In an interview, E1 reported E4 was bringing the clinical oversight documentation to the facility later that day.

4. In an interview, E1 acknowledged E1 failed to ensure a personnel record was maintained for a BHT to include documentation of clinical oversight, required in R9-10-115

Deficiency #2

Rule/Regulation Violated:

K. An administrator shall ensure that:
1. At least one personnel member is present and awake at the behavioral health residential facility when a resident is on the premises;

Evidence/Findings:

Based on documentation review and interview, the administrator failed to ensure at least one personnel member was awake at the behavioral health residential facility when a resident was on the premises. The deficient practice posed a risk as a personnel member was not awake to meet a resident's needs and ensure the health and safety of a resident.

Findings include:

1. A review of facility documentation revealed documents titled "Employee Schedule" for the months of January 2023 and February 2023. The schedule stated the following:
-January 24-27, E2, 24 hours worked each day, 1 client;
-January 28-29, E6, 24 hours worked each day, 1 client;
-January 30-31, E2, 24 hours worked each day, 1 client;
-February 1-3, E2, 24 hours worked each day, 1 client;
-February 4-5, E7, 24 hours worked each day, 1 client;
-February 6-10, E2, 24 hours worked each day, 1 client;
-February 11-12, E7, 24 hours worked each day, 1 client;
-February 13-17, E2, 24 hours worked each day, 1 client;
-February 18-19, E7, 24 hours worked each day, 1 client;
-February 20-24, E2, 24 hours worked each day, 1 client;
-February 25-26, E7, 24 hours worked each day, 1 client; and
-February 27-28, E2, 24 hours worked each day, 1 client.

2. A review of facility documentation revealed a policy and procedure titled "Daily Staffing Schedule" (dated May 2022). The policy stated "One staff member will be present and awake at the facility during bedtime hours."

3. In an interview, the Compliance Officer asked E1 if E2 or E7 remained awake at the facility for 48 or more hours at a time. E1 reported neither E2 or E7 were awake for more than 48 hours as listed on the schedule.

4. In an interview, E1 acknowledged E1 failed to ensure at least one personnel member was awake at the behavioral health residential facility when a resident was on the premises.

Deficiency #3

Rule/Regulation Violated:

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

Evidence/Findings:

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

Findings include:

1. A review of R2's (admitted June 30, 2023) medical record revealed documentation a medical practitioner performed a medical history and physical examination or a registered nurse performs a nursing assessment on a resident within 30 calendar days before admission or within 72 hours after admission was not available for review.

2. In an interview, E1 acknowledged E1 failed to ensure a medical practitioner performed a medical history and physical examination or a registered nurse performed a nursing assessment on a resident within 30 calendar days before admission or within 72 hours after admission.

Deficiency #4

Rule/Regulation Violated:

Evidence/Findings:

Based on record review and interview, the administrator failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident's admission. The deficient practice posed a TB exposure risk to residents.

Findings include:

R9-10-113(B) A health care institution ' s chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specified in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: a. Documentation of a negative Mantoux skin test or other tuberculosis screening test that: i. Is recommended by the U.S. Centers for Disease Control and Prevention (CDC), ii. Was administered within 12 months before the date the individual begins providing services at or on behalf of the health care institution or is admitted to the health care institution, and iii. Includes the date and the type of tuberculosis screening test; b. If the individual had a history of tuberculosis or documentation of latent tuberculosis infection, as defined in A.A.C. R9-6-1201, compliance with subsection (A)(2)(b); or c. If the individual had a positive Mantoux skin test or other tuberculosis screening test according to subsection (B)(1)(a) and does not have history of tuberculosis or documentation of latent tuberculosis infection, as defined in A.A.C. R9-6-1201, a written statement: i. That the individual is free from infectious tuberculosis, signed by a medical practitioner or local health agency, as defined in A.A.C. R9-6-101; and ii. Dated within 12 months before the date the individual begins providing services at or on behalf of the health care institution or is admitted to the health care institution;

1. A review of R2's (admitted June 30, 2023) medical record revealed documentation of evidence of freedom from infectious tuberculosis was not available for review.

2. In an interview, E1 acknowledged E1 failed to ensure a resident provided evidence of freedom from infectious tuberculosis before or within seven calendar days after the resident's admission.

Facility Information

Inspection History

INSP-0130961

Summary:

Deficiencies Found: 6

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #4

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #5

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #6

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

INSP-0058726

Summary:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

INSP-0058724

Summary:

Deficiencies Found: 16

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #4

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #5

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #6

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #7

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #8

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #9

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #10

Rule/Regulation Violated: