Former employee speaks out after state inspection of behavioral health facility

A behavioral health facility near Marana is facing state scrutiny after inspectors documented 11 deficiencies, raising questions about whether the home was equipped to care for adolescents with serious behavioral health needs. The findings involved the level of treatment provided, reporting of injuries and other incidents, and the physical condition of the residence. For families in the Tucson area who depend on residential programs for vulnerable young people, the report offers a troubling look at the challenges and risks inside one such facility.

State inspectors visited the Artemis Adolescent Healing Center on May 7 and May 8. Artemis operates four residential facilities in Arizona, and the Marana area home is licensed as a Behavioral Health Residential Facility that can house as many as 10 adolescents. Inspectors concluded the facility was providing an environment beyond what its license permits. The home is not authorized to deliver continuous treatment to people whose conditions significantly impair judgment, behavior, or reality recognition, or who may be a danger to themselves or others.

Arizona distinguishes residential treatment from inpatient care. A behavioral health residential facility serves people whose conditions limit their independence or require treatment to maintain or improve it. An inpatient facility provides continuous care for people who may be dangerous to themselves or others, unable to meet basic physical needs, persistently or acutely disabled, or gravely disabled. The inspection report indicated that some residents at Artemis needed that more intensive level of care.

Shawna Beckman, Artemis’ chief clinical officer, said many of the adolescents arrive after being stabilized at level one psychiatric hospitals. In her description, the facility is intended to be the next step after hospitalization. Beckman also said the inspection captured an unusually difficult period rather than a normal day at the home. She said residents’ needs can change from day to day and that the circumstances described in the report were not typical.

Tyra Johnson, who worked at the facility for several months as a care coordinator, offered a sharply different account. Johnson said she left in late February after feeling emotionally exhausted and crying frequently. She described the workplace as chaotic from her first day, including fights among residents that initially frightened her. Johnson said the experience continued to affect her after she quit and that she no longer felt like the same person. She told the station that adolescents displaying the behaviors described in the report should have been in a secure, locked setting without access to household features such as glass windows.

Inspectors also documented extensive damage and safety modifications throughout the home. Ten resident beds had mattress covers, bedspreads, and pillows, but no mattress pads, sheets, or pillowcases. Staff told inspectors that sheets and pillowcases had been removed because residents used them to self harm or as whips during fights. Curtains were also absent because staff considered them dangerous. Walls, including those in bedrooms, had been patched with drywall plaster. Several doors were covered with plywood fastened by screws or nails, and the primary bedroom, where four residents slept, had no door at all. Bedrooms lacked individual storage, while several bathroom drawers were missing.

The report said residents’ clothing and furniture were being kept in a locked garage. Inspectors found plastic bins labeled with residents’ names, along with dressers and nightstands. Staff said those items had been removed the night before because residents had tried to throw them out windows or at one another. Staff told inspectors that belongings remained locked in the garage but could be retrieved when residents asked for them. Beckman acknowledged destructive behavior, but characterized it as a result of adolescents’ impulsivity and developing brains. She said Artemis was trying to reduce immediate risks while addressing what caused a young person to escalate.

The inspection also found that incidents involving self harm and property damage were not consistently reported, according to the report. One March incident involved a resident who said they had swallowed screws. Inspectors said the resident remained at the home overnight, and hospital imaging the following day showed five screws had been ingested, including one in the colon. The resident required surgery. Beckman said Artemis documents every incident and conducts thorough investigations, but declined to discuss that specific case, citing client privacy.

Under Arizona Department of Health Services rules, a facility has 10 days after a deficiency is identified to submit a correction plan. Artemis agreed to pay $1,500 in civil fines after the inspection. Beckman said the organization is clarifying when incident reports are required and revising its admission and exclusion criteria. Those changes are intended to address both the state’s concerns about reporting and the question of whether residents are being admitted whose needs exceed the home’s license. Johnson said she spoke out because vulnerable young people need advocates. A subsequent report is expected to examine neighborhood concerns and the requirements for operating residential health facilities in Pima County neighborhoods.