Step Two Recovery Center: Intent to Revoke License
Photo: Google Maps Image, April 2018 - Step Two Recovery CenterClick the button below to access and download the Arizona Department of Health Services' Licensing Statement of Deficiencies for Step Two Recovery Center in Gilbert, Arizona. Additionally, you can visit azdhs.org to explore further information about Step Two Recovery Center’s licensing status.
BACKGROUND
In 2021, ESAAlliance introduced the Anonymous Mass Complaint Form, receiving over 300 grievances regarding residential and outpatient programs affiliated with the Enthusiastic Sobriety Recovery Program, established by Bob Meehan. By the end of 2022, ESAAlliance had compiled more than 80 specific complaints related to The Pathway Program, FullCircle Program, and Step Two Recovery Center. These complaints were subsequently forwarded to the Arizona Department of Health Services for review.
WHAT HAPPENED
The Bureau of Behavioral Health Facilities Licensing conducted an investigation into Step Two Recovery Center to assess whether the issues raised ESAAlliance’s complaint aligned with the licensing regulations. This investigation involved reviewing individual allegations, conducting interviews with staff and residents, making on-site observations, and examining facility records and documents. For the violations that were identified during the investigation, the bureau issued a Statement of Deficiencies to the facility, detailing each violation found. The facility was required to submit a corrective action plan describing how they would address the violations and prevent them from occurring again in the future.
SUMMARY OF CITATIONS
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Facility failed to develop and administer a fall prevention and recovery training program for staff; staff admitted unawareness of this requirement.
Rule A.R. S 36-420.01 Violation
Develop and administer training program on fall prevention and recovery.
Findings
No training program for fall prevention and recovery was developed or administered.
Personnel records for eight employees (E1 to E8) lacked documentation of required training.
Admission by E1 that there was no training program available and they were unaware of the requirement.
Evidence
Reviews of facility documentation and personnel records showed absence of the mandated training.
Interview with E1 confirmed the lack of training and awareness of the requirement.
Issue was corrected 70 days after initial finding.
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Facility failed to verify and document the qualifications of a staff member before they provided behavioral health services; administrator admitted the oversight.
Rule 706.B.2.a Violation
Verify and document personnel skills and knowledge before service provision.
Findings
E9's skills and knowledge were not verified or documented before they began providing behavioral health services.
Admission by E1 that E9's qualifications were not checked prior to service delivery.
Evidence
Personnel records review revealed missing verification for E9.
Interview with E1 confirmed the lack of verification.
Issue corrected 1 day after discovery.
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Facility failed to ensure staff member with driving restrictions did not transport residents; both staff member and administrator admitted to misunderstanding and ignoring these restrictions.
Rule 706.B.3.c Violation
Ensure qualified personnel for resident safety.
Findings
Staff member E2, with legal driving restrictions, transported residents, posing a safety risk.
Admissions by E2 and E1 about misunderstanding and non-compliance with driving restrictions.
Evidence
Personnel records showed E2's restricted driving status.
Interviews with E2 and E1 revealed E2 was allowed to transport residents despite restrictions.
Issue corrected the same day it was identified.
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Facility failed to provide up-to-date tuberculosis clearance for two employees interacting with residents; administrator acknowledged the lack of current documentation.
Rule 706.F.1-2 Violation
Provide evidence of TB clearance before service provision.
Findings
Two employees (E3 and E9) lacked up-to-date TB clearance documentation.
E9 worked with residents despite not being scheduled and lacking TB clearance.
Administrator E1 admitted missing TB documentation for E3 and E9.
Evidence
Personnel records and facility schedules reviewed; discrepancies in TB clearance documentation for E3 and E9 noted.
Compliance officers observed E9 working without listed clearance during facility tour.
Issue corrected 4 days after identification.
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Facility failed to maintain complete personnel records, specifically lacking orientation documentation for an employee; administrator admitted to the oversight.
Rule 706.G.3.c Violation
Maintain personnel records with documented orientation.
Findings
E9’s personnel record lacked documentation of completed orientation.
Administrator E1 admitted the documentation was missing.
Evidence
Personnel record review confirmed absence of orientation documentation for E9.
Admission from E1 during interview about the missing record.
Issue corrected 1 day after identification.
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Facility failed to maintain required legal documentation for eight personnel members, exposing vulnerable residents to potential risks; administrator admitted lack of awareness of these requirements.
Rule 706.G.3.e Violation
Maintain documentation of legal compliance for personnel as required by law.
Findings
Eight out of nine personnel lacked necessary legal documentation for compliance with specific Arizona statutes concerning criminal background and trials.
Administrator E1 admitted the absence of notarized forms certifying the absence of pending trials or convictions for serious offenses.
Evidence
Reviews of personnel records for E1, E2, E4, E5, E6, E7, E8, and E9 revealed missing documentation of compliance with A.R.S. §§ 36-411 and 36-425.03.
Interview with E1 confirmed the absence of required documentation and an awareness gap regarding these legal requirements.
Issue corrected 9 days after identification.
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Facility failed to properly document staffing schedules, specifically missing indications of on-call and present behavioral health professionals and registered nurses; administrator admitted to the oversight.
Rule 706.K.3.a Violation
Ensure daily staffing schedules accurately reflect all personnel, including on-call members.
Findings
Staffing schedules did not specify the presence or on-call status of essential personnel such as RNs or BHPs.
Discrepancies noted between actual personnel presence (E9 working) and the staffing schedule.
Administrator E1 admitted schedules did not include required details for on-call and present staff.
Evidence
Documentation review showed incomplete staffing schedules from January 16, 2023, through February 19, 2023.
Facility tour and personnel records review confirmed discrepancies in staffing documentation.
Issue corrected 1 day after identification.
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Facility failed to ensure a behavioral health professional was on-call, risking inadequate response to residents' behavioral health needs; administrator acknowledged the gap.
Rule 706.K.4 Violation
Ensure a behavioral health professional is always available, either present or on-call.
Findings
No documentation confirming a behavioral health professional (BHP) was on-call as required.
Administrator E1 confirmed BHP (E3) only met with residents at an outpatient center, not on-call for the facility.
Evidence
Staffing schedules reviewed, lacking on-call BHP documentation.
Personnel record and interview with E1 confirmed E3's limited availability and lack of on-call status.
Issue corrected 1 day after identification.
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Facility failed to conduct and document required medical assessments within specified timelines for three residents, potentially compromising their health and safety; administrator admitted to the oversight.
Rule 707.A.6 Violation
Conduct and document a medical history, physical examination, or nursing assessment either 30 days before or within 72 hours after resident admission.
Findings
Delayed or missing medical assessments for residents R1, R3, and R4.
Admissions and documentation delayed beyond the 72-hour requirement post-admission.
Administrator E1 acknowledged failure to meet required assessment and documentation timelines.
Evidence
Medical records review showed delays and omissions in assessments.
Interview with E1 confirmed non-compliance with required medical assessment timelines.
Issue corrected 4 days after identification.
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Facility failed to ensure timely review and sign-off of behavioral health assessments by a professional for two residents, risking inadequate care; administrator admitted the delay.
Rule 707.A.8.a Violation
Ensure behavioral health assessments are reviewed and signed by a qualified professional within 24 hours.
Findings
Behavioral health assessments for residents R1 and R3 were not reviewed and signed by a behavioral health professional within 24 hours.
Assessments delayed by five days, not meeting the required timeline.
Administrator E1 admitted the behavioral health professional failed to review and sign the assessments timely.
Evidence
Medical record review confirmed delays in professional review and sign-off.
Interview with E1 validated acknowledgment of non-compliance with the 24-hour review requirement.
Issue corrected 7 days after identification.
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Facility failed to document clinical justifications for restricting residents' phone calls, violating resident rights; both staff and residents reported restrictions without documented clinical reasons.
Rule 711.C.1 Violation
Document specific treatment purpose for activity restrictions in resident's medical record.
Findings
No justification documented for restricting phone calls for residents R1, R3, and R4 as required.
Facility's policy on phone calls did not align with documented clinical indications.
Admissions by staff and residents about phone call restrictions without proper documentation or clinical rationale.
Evidence
Review of medical records and facility policies showed lack of required documentation for treatment-based restrictions.
Interviews with staff and residents confirmed the lack of clinical documentation for restricting phone calls.
Issue corrected 7 days after identification.
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Facility failed to provide continuous protective oversight for minor residents, allowing them to engage in prohibited activities like smoking at an outpatient center; administrator acknowledged oversight lapses.
Rule 716.A.2.b Violation
Ensure continuous protective oversight for residents with limited ability to function independently.
Findings
Minors were allowed to smoke or vape during outings at an outpatient treatment center, contrary to the facility's policy of continuous protective oversight.
Residents used personal funds to obtain cigarettes through older patients, with staff awareness but without intervention.
Evidence
Facility policies and resident interviews confirmed the lack of oversight during outings.
Administrator E1 admitted the facility was aware of these activities but did not facilitate or prevent them.
Issue corrected 1 day after identification.
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Facility failed to provide behavioral health services on the premises as required, with most services conducted off-site at an outpatient center; administrator confirmed the discrepancy in service locations.
Rule 716.A.5 Violation
Ensure all listed behavioral health services are provided on the facility's premises.
Findings
Documentation and interviews revealed that the majority of behavioral health services were conducted at an outpatient treatment center, not on the facility premises as stated in the facility’s scope of services.
Residents attended group and individual counseling primarily off-site, with limited services provided at the residential facility itself.
Evidence
Treatment plans and progress notes indicated off-site service provision.
Residents and administrator interviews confirmed that most counseling sessions took place outside the facility.
Administrator requested off-site counseling session notes be brought to the facility for compliance review.
Issue corrected 1 day after identification.
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Facility failed to restrict minor residents' access to tobacco and nicotine products, despite awareness by staff, posing a health risk to the residents; administrator admitted to the oversight.
Rule 716.A.7.a Violation
Prevent resident access to materials or participation in activities that pose health or safety risks.
Findings
Minor residents were permitted to smoke or vape at an outpatient treatment center, using funds from their food allowances to purchase tobacco products through older patients.
Facility personnel were aware of and did not intervene in these activities, despite the health risks associated with tobacco and nicotine use by minors.
Evidence
Medical records and interviews with residents indicated access to and use of tobacco products by minors.
Administrator and staff acknowledged awareness of these activities and failed to enforce policies to prevent access to harmful substances.
Issue corrected 1 day after identification.
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Facility failed to ensure medication assistance was in compliance with physician orders for two residents, risking incorrect medication administration; administrator admitted lack of proper documentation and compliance.
Rule 718.C.6.a Violation
Ensure medication assistance complies with a physician's order.
Findings
Medications administered to residents R1 and R3 were not listed on any signed physician order documents.
Medication orders for "Spironolactone 50mg" and "Doxycycline 50mg" for R1, and specific instructions for R3's "Cetirizine Hydrochloride" were not formally documented.
Administrator E1 admitted receiving verbal orders from a medical practitioner that were not properly documented or verified.
Evidence
Review of Medication Administration Records (MAR) and supposed physician orders revealed discrepancies and missing signatures.
Interviews confirmed that the assistance in medication administration was not in compliance with formally documented orders.
Issue corrected 4 days after identification.
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Facility failed to securely store medications in a locked unit, leaving them in an unlocked bathroom cabinet; administrator acknowledged the failure to comply with storage regulations.
Rule 718.E.1 Violation
Medications must be stored in a locked and dedicated storage unit.
Findings
Medications prescribed to resident R1 were found in an unlocked cabinet in a bathroom, contrary to storage requirements.
Administrator E1 confirmed that medications were not stored according to the mandated secure and dedicated area.
Evidence
Direct observation by Compliance Officers during facility tour showed improper storage.
Administrator’s interview confirmed non-compliance with secure medication storage requirements.
Issue corrected 1 day after identification.
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Facility failed to provide a private room for treatment and visitors, compromising confidentiality and resident privacy; administrator acknowledged the lack and committed to repurposing office space for privacy.
Rule 722.B.1.a Violation
Ensure a private room is available for resident treatment and visitation.
Findings
No designated private room for treatment or visitors was available within the facility.
Counseling observed being conducted in non-private settings such as the facility’s outdoor back porch.
Administrator E1 and staff member E7 acknowledged the absence of a private room and outlined plans to convert office space to meet this requirement.
Evidence
Compliance Officers' observations during facility tour confirmed the lack of a private room.
Interviews with E1 and E7 validated the facility’s current non-compliance and plans for correction.
Issue corrected 1 day after identification.
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Facility failed to ensure bedroom clothing rods and hooks were designed to minimize self-injury risks; administrator acknowledged the fixtures were not appropriately safe.
Rule 722.B.8.k Violation
Bedrooms must have clothing rods or hooks designed to prevent self-injury.
Findings
Bedrooms featured closet rods supported by metal brackets and PVC pipes, which were not safety-designed to give way under pressure to prevent potential self-harm.
Administrator E1 admitted that the installed fixtures were not intended to minimize self-injury risks.
Evidence
Direct observation by Compliance Officers during a facility tour showed non-compliant fixtures.
E1's interview confirmed awareness of the issue and acknowledged the non-compliance.
Issue corrected 6 days after identification.
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Facility failed to provide required bi-weekly clinical oversight for a behavioral health technician, risking inadequate supervision and potential care deficiencies; administrator admitted to oversight lapses.
Rule 115.4 Violation
Ensure behavioral health technicians receive clinical oversight at least once every two weeks.
Findings
E7, a behavioral health technician, did not receive the required clinical oversight every two weeks as mandated.
Personnel records indicated irregular and insufficient oversight frequency compared to policy requirements.
Evidence
Review of "Team Clinical Oversight Summary" and "Individual Clinical Oversight" records showed gaps exceeding two weeks without oversight.
Administrator E1 confirmed the lack of compliance with the bi-weekly oversight requirement.
Issue corrected 3 days after identification.
WHAT HAPPENS NEXT
This settlement agreement outlines terms agreed upon between the Arizona Department of Health Services and MHTCL, LLC doing business as Step Two Recovery Center (the Licensee). The Department is responsible for safeguarding public health in Arizona and has the authority to regulate behavioral health facilities. The Licensee was issued a license to operate a behavioral health residential facility and was subject to an investigation resulting in multiple violations documented in a Statement of Deficiencies (SOD).
The Licensee received a Notice of Enforcement and later a Notice of Intent to Revoke Health Care Institution License, leading to an administrative hearing request. However, instead of proceeding with the hearing, the parties agreed to settle the matter through an Informal Settlement Conference (ISC), resulting in this Settlement Agreement
Click the button below to access and download the Arizona Department of Health Services' Licensing Settlement Agreement for Step Two Recovery Center in Gilbert, Arizona. Additionally, you can visit azdhs.org to explore further information about Step Two Recovery Center’s licensing status.
Photo: Google Maps Image, April 2018 - Step Two Recovery CenterSUMMARY OF SETTLEMENT AGREEMENT
The Licensee enters into the agreement without admitting liability.
The Licensee agrees to strict compliance with the terms of the agreement.
The agreement is effective upon approval by the Assistant Director of the Department's Division of Licensing Services.
The Licensee agrees to submit a Plan of Correction (POC) addressing the identified deficiencies.
The Licensee agrees to ensure the provision of specified behavioral health services at the facility.
The Licensee agrees to maintain personnel records, provide privacy for residents, and ensure the presence of qualified staff at all times.
The agreement includes provisions for enforcement actions in case of non-compliance.
The term of the agreement is three years.
Violations documented in the Statement of Deficiencies (SOD) and what the licensee agrees to correct:
Violation: Failure to maintain personnel records for each personnel member.
Correction: The licensee agrees to maintain personnel records for all personnel members throughout their period of service at the facility and for at least 24 months after their termination date.
Violation: Lack of verification and documentation of personnel members' skills before providing physical health services or behavioral health services.
Correction: The licensee agrees to verify and document personnel members' skills before providing services and ensure that sufficient personnel members with the necessary qualifications are present at the facility at all times.
Violation: Absence of a behavioral health professional present or on-call at the facility at all times.
Correction: The licensee agrees to ensure the presence of a behavioral health professional at the facility at all times, either physically or on-call.
Violation: Failure to provide privacy for residents to receive treatment or visitors.
Correction: The licensee agrees to ensure that residents have access to a room providing privacy for treatment sessions and visitor interactions.
Violation: Presence of conditions or situations where a resident or individual may suffer self-injury or physical injury, such as clothing rods, hooks, or ligature points.
Correction: The licensee agrees to maintain the facility to be free from conditions or situations posing risks of self-injury or physical injury, including removing or minimizing access to potential hazards like clothing rods or hooks.
Violation: Minors having access to cigarettes, e-cigarettes, or other nicotine/tobacco products.
Correction: The licensee agrees to prevent minors at the facility from accessing any nicotine or tobacco products under its continuous protective oversight.
If the licensee breaches the terms of the agreement, several consequences may occur, as outlined in the settlement agreement:
Notice of Non-Compliance (NON): The Department may issue a Notice of Non-Compliance to the licensee, specifying the violations and providing a cure period for correction.
Cure Period: Upon receiving a Notice of Non-Compliance, the licensee has a specified period, typically ten business days, to correct the violations outlined in the notice.
Enforcement Action: If the licensee fails to correct the violations within the cure period, the Department may take enforcement action. This action could include civil monetary penalties or even voluntary surrender of the healthcare institution license.
Compliance Enforcement: The licensee is required to comply with the enforcement action outlined in the Notice of Non-Compliance. Failure to comply with the enforcement action may result in further penalties or consequences.
No Right of Appeal: The licensee agrees that enforcement actions identified in a Notice of Non-Compliance are not subject to appeal under relevant statutes.
CALL TO ACTION: Parents, Recent or Current Group Members and Staff
If someone witnesses or experiences any of the violations outlined in the settlement agreement they may file a complaint with the Arizona Department of Health Services. The Division of Licensing Services Bureau of Behavioral Health Licensing provides this Online Complaint Form which allows anyone with knowledge or concerns about a suspected rule violation to submit a complaint through this web page. A complaint is a suspected violation of Arizona state rules and/or statutes governing the operations of licensed and unlicensed Behavioral Health facilities or providers.
If you suspect abuse, neglect, exploitation of a resident or if this is an emergency, please call 911 and/or another applicable first responder such as APS, DCS, or local law enforcement.
Document Evidence: It's essential to document any evidence related to the violation, including photographs, written records, or witness statements. This documentation can strengthen the complaint and provide supporting evidence if further action is necessary.
WHAT DOES THIS MEAN FOR US?
When survivors come together to speak out and file complaints, it's a powerful act of solidarity and bravery. It might feel like justice moves at a snail's pace, but every complaint filed is a step forward, showing that change is possible.
It's not always easy, and progress can feel frustratingly slow, but each complaint adds weight to our collective voice. It's a journey we're on together, filled with ups and downs, but our determination and unity can't be ignored.
Remember, our strength lies in our numbers and our willingness to stand up for what's right. Justice might take time, but with each complaint and each person who speaks out, we're making a difference, one step at a time.
