SIERRA VISTA — The state has revoked the licenses of Mary’s Mission, a local residency and rehabilitation program for boys and girls.
Officials have called Mary’s Mission residents some of the toughest children to place in the juvenile system because of their backgrounds and mental health issues. The residents are 11 to 17 years of age.
The decision from an administrative law judge and the designee for the interim director of the Arizona Department of Health Services was issued earlier this week and states that Mary’s Mission must “promptly cease and desist all actions.”
The decision was based on more than 40 violations at the two facilities combined — the boys facility in Sierra Vista and the girls’ unit in Hereford — as well as concerns listed by Administrative Law Judge Tammy L. Eigenheer that Mary’s Mission had provided “false and misleading documents” to the surveyors who inspected their facilities.
The ruling to shut down the two units comes after surveyors from the Department of Health visited both locations last year and cited Director William Lacey with the myriad violations.
Lacey and his staff appealed the findings and after a four-day hearing in Phoenix in early December, Eigenheer issued her ruling on Feb. 22, affirming the observations made by the surveyors.
Robert Lane, a designee for health department interim Director Don Herrington, concurred with Eigenheer’s decision on March 15 and dismissed Mary’s Mission’s appeal.
Lacey and officials at Mary’s Mission have until April 15 to request another hearing on the matter with the Clerk of the Arizona Department of Health Services or until April 20 to request a judicial review in Cochise County Superior Court.
Mary’s Mission Operations Manager Chris Anable told the Herald/Review on Friday afternoon they likely will take the issue to Superior Court.
Anable and Lacey told the Herald/Review in December they were being targeted unfairly by the state surveyors and a fire marshal who were nitpicking and finding fault with the way the facilities were run. Anable and Lacey provided the newspaper with emails between one of the surveyors and two fire marshals that attorneys for Mary’s Mission said showed there was collusion between the officials to close Mary’s Mission.
Lacey said he is disappointed with the judge’s ruling, calling it “unfair.”
“There were never any health and safety issues,” Lacey said. “It was all administrative issues. The judge also never mentioned anything about the collusion.
“The main thing I want people to know is that no kid’s life was ever in jeopardy. I take care of my kids. The health and safety of the kids was never in danger.”
Lacey said the facilities can remain open while his attorneys file a motion to have the case reviewed in Cochise County Superior Court. The Herald/Review asked the health department about that, but a spokesman said the agency was declining comment.
In her 24-page findings of fact on Feb. 22, Eigenheer stated that in both the boys’ and girls’ facilities the issues discovered were in violation of state law and pose a “direct risk to the life, health and safety of residents of the boys and girls unit.”
There were 23 violations provided for the boys’ facility and 27 for the girls, Eigenheer’s decision shows. The surveyors focused on 10 violations in the boys’ section and 14 in the girls’ unit, as “forming the basis of the Notice of Intent to Revoke.”
Some of the violations at the boys’ facility in Sierra Vista include:
Failure by administrators to designate in writing a person who would be responsible for the boys’ unit when other officials were not present.
Failure by administrators to ensure that 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 and documented that in the patient’s medical record.
Failure by the administrator to ensure a resident was discharged from the facility when the resident’s treatment needs were not consistent with the services that the facility was authorized and able to provide.
Failure by the administrator to ensure that assistance in the self-administration of medication provided to a resident was in compliance with an order and documented in the medical record.
Some of the violations at the girls’ unit in Hereford include:
Mary’s Mission enclosed a carport and expanded the facility to include that area, adding an additional bedroom and living room without Department approval, appearing to increase capacity beyond what they were licensed to provide and also not ensuring the space was large enough to comply with the 60-square-feet per resident requirement.
Failure by the administrator to designate in writing someone who was present on the premises when the administrator was not present.
Failure by administrator to ensure that medications taken by residents were documented in the resident’s medical records.
Failure of administrator to ensure that hot water temperatures were maintained between 95 and 120 degrees.
Failure of administrator to ensure that poisonous or toxic materials were stored in a locked area.
Failure by administrator to ensure that a water source not regulated by state environmental quality officials was tested at least once a year for bacteria.
Failure by the administrator to ensure that a resident had a shatter-proof mirror and that a resident had a clothing rod or hook in her closet that could have been used by the resident to harm herself.
In particular, the judge was troubled over a falsified fire inspection report by a Mary’s Mission employee that was doctored to make it look as if the girls’ facility in Hereford had been inspected. The inspection report was actually for the boys’ facility in Sierra Vista.
Eigenheer also noted that there was a falsified roster for the boys’ facility making it look as if the unit had only 16 boys — the amount approved by the state.
“The falsified current roster list for the boys’ unit was indicative of Appellants’ willingness to knowingly provide false and misleading information to the Department,” Eigenheer wrote.
The judge also mentioned the enclosure of the carport at the girls facility as “problematic.”
“Taken together, the totality of the violations noted in both the boys’ unit and the girls’ unit established that Appellant violated the Department’s statutes and rules and were in substantial violation of the requirements for licensure resulting in the health and safety of the residents being in immediate danger.”