THESE ITEMS WERE NOTED AS NOT CORRECTED AS OF THE DATE (02/24/2009) I CHECKED ON MS. COURTNEY’S LICENSE. IF IT TAKES MORE THAN TWO YEARS TO CORRECT DEFICIENCIES, DO YOU WANT TO GIVE YOUR CHILD INTO HER CARE?

From an inspection done in 2006 by the state of Arizona on Spring Ridge Academy:

An on-site investigation, and a discussion with the Clinical Director, Admissions Director and Assistant Admissions Director , revealed the licensee did not ensure a restraint or seclusion does not take place. The agency cannot be authorized to provide restraint or seclusion services.

Findings include:

A Level III Behavioral Health Residential Agency cannot be authorized to perform restraint services.

A discussion with the Clinical Director, Admissions Director and Assistant Admissions Director on group process the licensee conducted with clients revealed the use of restraint.

It was discussed at the exit interview with the Clinical Director, Admissions Director and Assistant Admissions Director that the licensee cannot perform a restraint.


ALSO

A review of three client records revealed three of three client records reviewed, did not contain an assessment before treatment was initiated.

The regulation requiring a behavioral health professional or behavioral health technician, under the supervision of a behavioral health professional, initiate an assessment of a client before treatment is initiated was discussed with the Admissions Director, Clinical Director and Assistant Admissions Director during the exit interview.


A form was present in the file that was titled Initial Assessment and the document was signed by the Admissions Director. A review of the Admissions Director's personnel record indicated she was not qualified to function as a behavioral health professional.

A review of three client records revealed three of the three client records reviewed, the records for client #1, #2, and #3, contained documentation verifying the assessments were conducted by a behavioral health technician, however the records did not contain documentation the assessments were reviewed by a behavioral health professional to ensure the assessment information identified the behavioral health services needed by the client and whether the client needed medical services. Specifically:

The Clinical Director stated that they do use a documented assessment from a non affiliated agency if assessment was within the last 12 months. However, the licensee did not have a Behavioral Health Professional or Behavioral Health Technician update the documented assessment to include any changes to the client's condition since the assessment was completed.

Initial assessments of client 1,2 and 3 were not contained in their client record or completed before treatment was initiated. The initial assessments for client 1,2 and 3 were not provided for review when requested.

The regulation requiring an assessment be conducted and documented by a behavioral health technician, and is reviewed by a behavioral professional to ensure that the assessment information identifies the behavioral health services needed by the client and whether the client needs medical services was discussed with the Clinical Director, Admissions Director and Assistant Admissions Director on June 9, 2006 during the exit interview.

ALSO:

A review of three client records and a staff interview with the Clinical Director, Admissions Director and Assistant Admissions Director revealed three of the three client records reviewed, did not contain an initial treatment plan developed for the client based on the initial assessment of the client.

Findings include:

A review of three client records revealed three of the three client records reviewed, client #1, #2 and #3, were receiving behavioral health services from the licensee and contained initial treatment plans but did not contain an initial treatment plan developed by the licensee.

However, the licensee had not conducted an initial assessment for each client and the initial treatment plan was not based upon the initial assessment.

During an interview, the clinical director, Admissions Director and Assistant Admissions Director acknowledged the clients were receiving behavioral health services from the licensee and did not contain an initial treatment plan based on the initial assessment of the client.

ALSO:

A review of ten personnel records, the program description and a discussion with the Assistant Clinical Director, Admissions Director and Assistant Admissions Director revealed the licensee did not ensure an emergency safety response is only used by a staff member who has documentation of successful completion annually of a training program in crisis intervention from an organization nationally recognized for providing training in crisis intervention.

Findings include:

The personnel records for staff members #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10 did not contain