State inspectors visited six Southwest Key facilities. Here’s what they found.




A Southwest Key facility in Phoenix. Photo by Jerod MacDonald-Evoy | Arizona Mirror

A suicidal child tried to hurt themselves in Southwest Key facility in Phoenix, but 911 was never called. A child in a Glendale shelter was given antidepressant medication, but there was no medical record of why the drug was needed. Other children with food allergies and food intolerance vomited and lost weight, and didn’t have specialized meals provided to them in Mesa, Phoenix and Tucson shelters operated by Southwest Key.

Those were some of the findings inspectors from the Arizona Department of Health Services noted in visits to six Southwest Key facilities in Phoenix, Glendale, Mesa, and Tucson, between January 22 and March 28.

The reviews were part of the process of reopening Southwest Key shelters, which ADHS placed on an admissions freeze as part of an October settlement. The agreement stemmed from an ADHS notice to revoke all of Southwest Key licenses after it found record-keeping violations, and the company blew the deadline to correct it.

The inspection reports are posted on the ADHS’s database for deficiencies recorded at facilities it licenses, AZcarecheck.com.

In total, state inspectors gave out 65 citations. All were corrected, according to the reports. None resulted in any enforcement action, penalties or fines, the records show.

Inspections show poor records-keeping, food allergies and language accommodations disregarded

The ADHS inspection reports didn’t disclose the names, ages or genders of either the children or employees. These are some of the findings ADHS inspectors noted:

  • In a Phoenix facility, 911 was not called on two consecutive nights when a child tried to hurt themselves. The child had entered the facility with “suicidal ideation concerns,” and had been experiencing emotional distress. One night, the child removed the protection around an electrical outlet in their room, and tried to stick a finger in the outlet. Staff didn’t call 911 to report self-harm, nor did they file an incident report as required by federal guidance. The next night, the same child used an orange cone to break an electrical outlet, and then tried to use the broken pieces to hurt themselves. Again, 911 was not called. Staff filed an incident report, but it didn’t document the child had attempted self-harm. The incident occurred Dec. 15-16, 2018.
  • A minor who had become aggressive towards another child in a Phoenix facility was physically restrained by several employees. The child was bear-hugged from behind, lifted and carried out into a hallway by an employee. Another employee then held the child by the wrists, and later by the shoulders. Then two staff members held the minor by the arms as they walked down the hallway. Later, six employees were present in a classroom where the child continued to misbehave. Staff filed an incident report, but didn’t document the restraints used. ADHS inspectors found out by reviewing surveillance video. The incident took place on Sept. 25, 2018.
  • In a Glendale shelter, a minor was a given the antidepressant drug Sertraline, commonly known as Zoloft, once a day. There was no record of a medical assessment of the child’s behavior that warranted them receiving the medication.
  • In Mesa, a medical exam showed a child — who had a food allergy -— had lost three pounds and had not been finishing meals. Staff were supposed to observe and document the meals the minor ate for the subsequent month, but didn’t. That minor was also given “food items prohibited by the medical practitioner.” Similarly, in a Phoenix facility, no documentation was kept on whether two minors who were lactose intolerant had been given a specialized diet. In Tucson, a child was served the food they had reported they were allergic and intolerant to. There was no record of specialized diets for two minors in that Tucson shetler who reported food allergies.
  • Language accommodations were not provided in several facilities. In Tucson, a minor fell in the bathroom and injured their head. Their medical record shows a medic did a pain assessment without a language interpreter, which is required. Two days later, during a follow-up exam, no interpreter was present. Four days after the fall, the minor’s injury had a mild inflammation, and they were given ibuprofen. The minor said they had constant headaches in class. No language interpreter was used.
  • A minor at a Glendale facility was injured in a car accident. The child was traveling with two staff members when their car was rear-ended at a stop light. The minor was taken to the hospital, and a cast placed for a fracture on their left wrist. ADHS was not notified of the accident. State rules require notification when a resident of the facility “has an accident that requires immediate intervention by an emergency medical services provider.”
  • A Glendale facility had several hazardous tools accessible to the children, like lawn maintenance tools, construction material and cleaning equipment.
  • In Phoenix, all of the 11 medical records reviewed by inspectors had incomplete behavioral health assessments. In other facilities, there were no records of the required medical assessment upon admission or prior to release from the facility.
  • In a Mesa shelter, there was no documentation showing the head cook at the facility had contacted Southwest Key’s licensed dietitian to serve food that met the nutritional needs of the minors there.
  • In Mesa, two employees didn’t have the required documentation showing they were free from infectious tuberculosis.

7 of 11 Southwest Key facilities in Arizona have reopened

Southwest Key is the country’s largest operator of shelters for migrant youth.

The minors in facilities like Southwest Key are migrants, mostly teenage boys from Central America, who arrived in the U.S. alone to seek protection or were separated from their parent or family member after entering the country. They are in the custody of the U.S. Department of Health and Human Services’ Office of Refugee Resettlement and are in the shelters pending reunification with their families or release to sponsors in the U.S.

There are more than 168 migrant youth facilities in 23 states, according to HHS.

Southwest Key has 11 licenses to operate residential behavioral health facilities for children in Arizona, with the capacity to house 1,035 children.

Since the October settlement, ADHS and Southwest Key have met regularly. The health department allowed the first facility to reopen on Feb. 28.

“We have worked closely with ADHS to ensure our policies, procedures and physical environments fully comply with the State’s licensing requirements,” Southwest Key spokesman Neil Nowlin said in a statement.

Only four of its 11 facilities in Arizona still have state-mandated admissions restrictions, ADHS said. Three of them are part of the Casa Campbell program, which has four facilities in Phoenix, Glendale and Peoria and beds for 128 children. Casa Kokopelli in Mesa, with more than 300 beds, has been allowed to operate at 50 percent capacity pending further inspections, ADHS said.

As of May 9, there were about 505 children in Southwest Key shelters in Arizona, according to HHS.

Last year, the federal government shut down one Southwest Key facility in Youngtown after reports of staff physically abusing three children. That was after media reports showed there were several instances of sexual abuse at migrant youth shelters in Arizona, including one of a HIV-positive man who abused seven boys. The Maricopa County Sheriff’s Office and the Maricopa County Attorney’s Office reviewed the Youngtown incidents and concluded no crimes were committed.

Southwest Key also closed its largest operation in Arizona, Casa Phoenix, as part of an October settlement with ADHS. Nowlin previously told Arizona Mirror it is “evaluating options” related to reopening the two shuttered shelters.

The controversies surrounding Southwest Key led to legislative changes this year. A new state law gives ADHS more discretion to inspect child behavioral health facilities, and requires reporting of serious incidents. Uncage and Reunite Families, an advocacy group for immigrant youth, said the new law doesn’t do enough.

Update: This story was updated to include a statement from Southwest Key.

Laura Gómez
Reporter Laura Gómez Rodriguez covers state politics and immigration for the Arizona Mirror. She worked for The Arizona Republic and La Voz Arizona for four years, covering city government, economic development, immigration, politics and trade. In 2017, Laura traveled the length of the U.S.-Mexico border for “The Wall,” the Pulitzer Prize-winning project produced by The Arizona Republic and USA Today Network. She was named Best Investigative Reporter by Phoenix Magazine in its 2018 newspaper category and has been honored by the Arizona Press Club for Spanish-language news and feature reporting. She is a native of Bogotá, Colombia and lived in Puerto Rico and Boston before moving to Phoenix in 2014. Catch her researching travel deals, feasting on mariscos or playing soccer.

1 COMMENT

  1. How can anybody be called a “reporter” who writes an ignorant, almost illiterate sentence like this: A suicidal child tried to hurt themselves in Southwest Key facility in Phoenix, but 911 was never called.
    And why is there no copy editor to catch such an atrocity?
    An important topic is rendered valueless by such poor writing.

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