Fort Behavioral Health

Liability Insurance is expired. Operation did not provide updated documentation.

Resolution: Corrected: 2025-02-24

Liability Insurance is expired. Operation did not provide updated documentation.

Resolution: Corrected: 2025-02-24

Operation health inspection was not completed 12 months from the last inspection. The last health inspection was completed 10/23/2023.

Resolution: Corrected: 2025-06-30

Liability Insurance is expired. Operation did not provide updated documentation.

Resolution: Corrected: 2025-02-24

Operation health inspection was not completed 12 months from the last inspection. The last health inspection was completed 10/23/2023.

Resolution: Corrected: 2025-06-30

Operation health inspection was not completed 12 months from the last inspection. The last health inspection was completed 10/23/2023.

Resolution: Corrected: 2025-06-30

2 of 2 child files reviewed did not indicate signatures from the children being admitted. During a follow up inspection on 12/8/2023, no documentation was received to support compliance for this standard due to administrators not being available. One admin was on leave and the other attending a family emergency.

Resolution: Corrected: 2023-12-11

2 of 2 child files reviewed did not indicate signatures from the children being admitted. During a follow up inspection on 12/8/2023, no documentation was received to support compliance for this standard due to administrators not being available. One admin was on leave and the other attending a family emergency.

Resolution: Corrected: 2023-12-11

2 of 2 child files reviewed did not indicate signatures from the children being admitted. During a follow up inspection on 12/8/2023, no documentation was received to support compliance for this standard due to administrators not being available. One admin was on leave and the other attending a family emergency.

Resolution: Corrected: 2023-12-11

2 of 2 child files reviewed did not indicate signatures from the children being admitted.

Resolution: Corrected: 2023-11-24

2 of 2 child files reviewed did not indicate signatures from the children being admitted.

Resolution: Corrected: 2023-11-24

2 of 2 child files reviewed did not indicate signatures from the children being admitted.

Resolution: Corrected: 2023-11-24

2 of 4 employee files does not include job description for current job title.

Resolution: Corrected: 2023-11-02

2 of 4 employee files does not include job description for current job title.

Resolution: Corrected: 2023-11-02

2 of 4 employee files did not include date of employment.

Resolution: Corrected: 2023-11-02

2 of 4 employee files did not include date of employment.

Resolution: Corrected: 2023-11-02

2 of 4 employee files does not include job description for current job title.

Resolution: Corrected: 2023-11-02

2 of 4 employee files did not include date of employment.

Resolution: Corrected: 2023-11-02

A person who signed the admission assessment admitted to not conducting it.

Resolution: Corrected: 2023-11-21

A person who signed the admission assessment admitted to not conducting it.

Resolution: Corrected: 2023-11-21

A person who signed the admission assessment admitted to not conducting it.

Resolution: Corrected: 2023-11-21

Discharge summary does not include child's reaction to discharge.

Resolution: Corrected: 2023-11-21

Discharge summary does not include child's reaction to discharge.

Resolution: Corrected: 2023-11-21

Discharge summary does not include child's reaction to discharge.

Resolution: Corrected: 2023-11-21

Condition #1 - Met Condition #2 - Met Condition #3 - Met Condition #4 - Met Condition #5 - Met Condition #6 - Met Condition #7 - Met Condition #8 - Met Condition #9 - Met Condition #10 - Met Condition #11 - Not Met Condition #12 - Met Condition #13 - Met Condition #14 - Met Condition #15 - Met

Resolution: Corrected: 2023-09-29

Medication log pill count shows a child was given more medication than instructed.

Resolution: Corrected: 2023-09-27

Condition #1 - Met Condition #2 - Met Condition #3 - Met Condition #4 - Met Condition #5 - Met Condition #6 - Met Condition #7 - Met Condition #8 - Met Condition #9 - Met Condition #10 - Met Condition #11 - Not Met Condition #12 - Met Condition #13 - Met Condition #14 - Met Condition #15 - Met

Resolution: Corrected: 2023-09-29

Medication log pill count shows a child was given more medication than instructed.

Resolution: Corrected: 2023-09-27

Condition #1 - Met Condition #2 - Met Condition #3 - Met Condition #4 - Met Condition #5 - Met Condition #6 - Met Condition #7 - Met Condition #8 - Met Condition #9 - Met Condition #10 - Met Condition #11 - Not Met Condition #12 - Met Condition #13 - Met Condition #14 - Met Condition #15 - Met

Resolution: Corrected: 2023-09-29

Medication log pill count shows a child was given more medication than instructed.

Resolution: Corrected: 2023-09-27

The operation was out of ratio when a unit of 11 children were left in the care of 2 caregivers, when 3 caregivers were required. One child was indicated to be on one-on-one supervision. The Administrator did not ensure the operation had sufficient staff to care for children in care. An acting administrator left the facility and did not provide a plan to mitigate risk to children while the unit was out of ratio.

Resolution: Corrected: 2024-07-10

At 17:30, after being injured, a child was observed to bleed from the eye, enough to soak a shirt and cover the floor. The operation did not contact EMS until 17:50

Resolution: Corrected: 2024-07-10

This standard was found deficient as part of a DFPS Investigation.

Resolution: Corrected: 2024-07-10

Caregivers did not provide appropriate supervision and environment to children when an acting administrator and supervisor on duty left one caregiver to care for 10 children. Children in care engaged in a physical altercation and the single caregiver was unable to de-escalate the physical altercation and ensure child safety. As a result, one child sustained a significant physical injury. The ratio required at the time of the incident was to be 1 caregiver to every 5 children.

Resolution: Corrected: 2024-07-10

Caregivers did not provide appropriate supervision and environment to children when an acting administrator and supervisor on duty left one caregiver to care for 10 children. Children in care engaged in a physical altercation and the single caregiver was unable to de-escalate the physical altercation and ensure child safety. As a result, one child sustained a significant physical injury. The ratio required at the time of the incident was to be 1 caregiver to every 5 children.

Resolution: Corrected: 2024-07-10

The operation was out of ratio when a unit of 11 children were left in the care of 2 caregivers, when 3 caregivers were required. One child was indicated to be on one-on-one supervision. The Administrator did not ensure the operation had sufficient staff to care for children in care. An acting administrator left the facility and did not provide a plan to mitigate risk to children while the unit was out of ratio.

Resolution: Corrected: 2024-07-10

The operation was out of ratio when a unit of 11 children were left in the care of 2 caregivers, when 3 caregivers were required. One child was indicated to be on one-on-one supervision. The Administrator did not ensure the operation had sufficient staff to care for children in care. An acting administrator left the facility and did not provide a plan to mitigate risk to children while the unit was out of ratio.

Resolution: Corrected: 2024-07-10

The operation was out of ratio when two caregivers were left to care for 11 children. The operation continued to be out of ratio when one caregiver was left to care for ten children.

Resolution: Corrected: 2024-07-10

The operation was out of ratio when two caregivers were left to care for 11 children. The operation continued to be out of ratio when one caregiver was left to care for ten children.

Resolution: Corrected: 2024-07-10

At 17:30, after being injured, a child was observed to bleed from the eye, enough to soak a shirt and cover the floor. The operation did not contact EMS until 17:50

Resolution: Corrected: 2024-07-10

This standard was found deficient as part of a DFPS Investigation.

Resolution: Corrected: 2024-07-10

Caregivers did not provide appropriate supervision and environment to children when an acting administrator and supervisor on duty left one caregiver to care for 10 children. Children in care engaged in a physical altercation and the single caregiver was unable to de-escalate the physical altercation and ensure child safety. As a result, one child sustained a significant physical injury. The ratio required at the time of the incident was to be 1 caregiver to every 5 children.

Resolution: Corrected: 2024-07-10

This standard was found deficient as part of a DFPS Investigation.

Resolution: Corrected: 2024-07-10

The operation was out of ratio when two caregivers were left to care for 11 children. The operation continued to be out of ratio when one caregiver was left to care for ten children.

Resolution: Corrected: 2024-07-10

At 17:30, after being injured, a child was observed to bleed from the eye, enough to soak a shirt and cover the floor. The operation did not contact EMS until 17:50

Resolution: Corrected: 2024-07-10

Condition #1: Progress reviews for the improvement plan were not available for review. Condition #12: Changes to the personnel file audit were not observed or that the personnel file was still missing the job description, person responsible for the changes, due date, and correction date.

Resolution: Corrected: 2023-09-15

Condition #1: Progress reviews for the improvement plan were not available for review. Condition #12: Changes to the personnel file audit were not observed or that the personnel file was still missing the job description, person responsible for the changes, due date, and correction date.

Resolution: Corrected: 2023-09-15

Condition #1: Progress reviews for the improvement plan were not available for review. Condition #12: Changes to the personnel file audit were not observed or that the personnel file was still missing the job description, person responsible for the changes, due date, and correction date.

Resolution: Corrected: 2023-09-15

Child in care, with history of self-harming, continue to cut and scratched herself.

Resolution: Corrected: 2024-01-12

Child in care, with history of self-harming, continue to cut and scratched herself.

Resolution: Corrected: 2024-01-12

Child in care, with history of self-harming, continue to cut and scratched herself.

Resolution: Corrected: 2024-01-12

4 of 6 child files reviewed had preliminary service plans that were signed outside of 72 hours.

Resolution: Corrected: 2023-09-08

4 of 6 child files reviewed had preliminary service plans that were signed outside of 72 hours.

Resolution: Corrected: 2023-09-08

2 of 6 employee files reviewed had suicide prevention training that did not include the number of training hours on the certificates.

Resolution: Corrected: 2023-09-08

Condition #1 - Does not meet Condition #2 - Met Condition #3 - Met Condition #4 - Met Condition #5 - Met Condition #6 - Met Condition #7 - Met Condition #8 - Met Condition #9 - Met Condition #10 - Met Condition #11 - Met Condition #12 - Does Not Meet Condition #13 - Met Condition #14 - Met Condition #15 - Met

Resolution: Corrected: 2023-09-06

2 of 6 employee files reviewed had suicide prevention training that did not include the number of training hours on the certificates.

Resolution: Corrected: 2023-09-08

4 of 6 child files reviewed had preliminary service plans that were signed outside of 72 hours.

Resolution: Corrected: 2023-09-08

Condition #1 - Does not meet Condition #2 - Met Condition #3 - Met Condition #4 - Met Condition #5 - Met Condition #6 - Met Condition #7 - Met Condition #8 - Met Condition #9 - Met Condition #10 - Met Condition #11 - Met Condition #12 - Does Not Meet Condition #13 - Met Condition #14 - Met Condition #15 - Met

Resolution: Corrected: 2023-09-06

Condition #1 - Does not meet Condition #2 - Met Condition #3 - Met Condition #4 - Met Condition #5 - Met Condition #6 - Met Condition #7 - Met Condition #8 - Met Condition #9 - Met Condition #10 - Met Condition #11 - Met Condition #12 - Does Not Meet Condition #13 - Met Condition #14 - Met Condition #15 - Met

Resolution: Corrected: 2023-09-06

2 of 6 employee files reviewed had suicide prevention training that did not include the number of training hours on the certificates.

Resolution: Corrected: 2023-09-08

Non-prescription medication provided to a child in care was not documented on the medication log.

Resolution: Corrected: 2023-10-17

Policy and procedures require that only an LVN, RN or medication aide administered medication to children in care. This procedure was not followed.

Resolution: Corrected: 2023-10-17

Non-prescription medication provided to a child in care was not documented on the medication log.

Resolution: Corrected: 2023-10-17

Incident report does not indicate a restraint was used.

Resolution: Corrected: 2023-10-17

Non-prescription medication provided to a child in care was not documented on the medication log.

Resolution: Corrected: 2023-10-17

Policy and procedures require that only an LVN, RN or medication aide administered medication to children in care. This procedure was not followed.

Resolution: Corrected: 2023-10-17

Incident report does not indicate a restraint was used.

Resolution: Corrected: 2023-10-17

Policy and procedures require that only an LVN, RN or medication aide administered medication to children in care. This procedure was not followed.

Resolution: Corrected: 2023-10-17

Incident report does not indicate a restraint was used.

Resolution: Corrected: 2023-10-17

Two children at the operation were not supervised in accordance with the information that is described and documented in each child' s individual service plan.

Resolution: Corrected: 2023-11-13

Two children at the operation were not supervised in accordance with the information that is described and documented in each child' s individual service plan.

Resolution: Corrected: 2023-11-13

Two children at the operation were not supervised in accordance with the information that is described and documented in each child' s individual service plan.

Resolution: Corrected: 2023-11-13

Two children in care (15 and 17 years of age) were involved in inappropriate sexualized behavior while placed at the operation, and the caregiver was unaware of the children's activity.

Resolution: Corrected: 2023-11-13

A caregiver failed to provide appropriate supervision which allowed two children to engage in inappropriate contact while on duty at the operation.

Resolution: Corrected: 2023-11-13

A caregiver failed to provide appropriate supervision which allowed two children to engage in inappropriate contact while on duty at the operation.

Resolution: Corrected: 2023-11-13

Two children in care (15 and 17 years of age) were involved in inappropriate sexualized behavior while placed at the operation, and the caregiver was unaware of the children's activity.

Resolution: Corrected: 2023-11-13

Two children in care (15 and 17 years of age) were involved in inappropriate sexualized behavior while placed at the operation, and the caregiver was unaware of the children's activity.

Resolution: Corrected: 2023-11-13

A caregiver failed to provide appropriate supervision which allowed two children to engage in inappropriate contact while on duty at the operation.

Resolution: Corrected: 2023-11-13

There was a toilet that was clogged and was not in working order.

Resolution: Corrected at inspection

There was a toilet that was clogged and was not in working order.

Resolution: Corrected at inspection

There was a toilet that was clogged and was not in working order.

Resolution: Corrected at inspection

Serious incident report does not indicate the specific emergency behavior technique.

Resolution: Corrected: 2023-11-07

Serious incident report does not indicate the specific emergency behavior technique.

Resolution: Corrected: 2023-11-07

Children in care were allowed to remain in the same proximity when children were restrained, which resulted in a restrained child being kicked.

Resolution: Corrected: 2023-11-07

Children in care were allowed to remain in the same proximity when children were restrained, which resulted in a restrained child being kicked.

Resolution: Corrected: 2023-11-07

Serious incident report does not indicate the specific emergency behavior technique.

Resolution: Corrected: 2023-11-07

Children in care were allowed to remain in the same proximity when children were restrained, which resulted in a restrained child being kicked.

Resolution: Corrected: 2023-11-07

5 of 5 child files did not have immunization records.

Resolution: Corrected: 2023-08-08

5 of 5 child files reviewed did not have TB test results. 1 of 5 employee files did not have TB test results.

Resolution: Corrected: 2023-08-08

2 of 5 employee files did not have documentation of education.

Resolution: Corrected: 2023-08-01

Condition #1: Met Condition #2: Met Condition #3: Not Met - 11 out of 30 employees hired or rehired did not have a comprehensive assessement. Condition #4: Met Condition #5: Met Condition #6: Met Condition #7: Met Condition #8: Met Condition #9: Met Condition #10: Met Condition #11: Met Condition #12: Met Condition #13: Not Met - 5 of 5 service plans audits were missing required documentation. Condition #14: Met Condition #15: Met

Resolution: Corrected: 2023-08-01

5 of 5 child files did not have immunization records.

Resolution: Corrected: 2023-08-08

5 of 5 child files did not have dental visit scheduled.

Resolution: Corrected: 2023-08-08

Condition #1: Met Condition #2: Met Condition #3: Not Met - 11 out of 30 employees hired or rehired did not have a comprehensive assessement. Condition #4: Met Condition #5: Met Condition #6: Met Condition #7: Met Condition #8: Met Condition #9: Met Condition #10: Met Condition #11: Met Condition #12: Met Condition #13: Not Met - 5 of 5 service plans audits were missing required documentation. Condition #14: Met Condition #15: Met

Resolution: Corrected: 2023-08-01

5 of 5 child files did not have dental visit scheduled.

Resolution: Corrected: 2023-08-08

5 of 5 child files reviewed did not have TB test results. 1 of 5 employee files did not have TB test results.

Resolution: Corrected: 2023-08-08

2 of 5 employee files did not have documentation of education.

Resolution: Corrected: 2023-08-01

5 of 5 child files reviewed did not have TB test results. 1 of 5 employee files did not have TB test results.

Resolution: Corrected: 2023-08-08

2 of 5 employee files did not have documentation of education.

Resolution: Corrected: 2023-08-01

5 of 5 child files did not have immunization records.

Resolution: Corrected: 2023-08-08

Condition #1: Met Condition #2: Met Condition #3: Not Met - 11 out of 30 employees hired or rehired did not have a comprehensive assessement. Condition #4: Met Condition #5: Met Condition #6: Met Condition #7: Met Condition #8: Met Condition #9: Met Condition #10: Met Condition #11: Met Condition #12: Met Condition #13: Not Met - 5 of 5 service plans audits were missing required documentation. Condition #14: Met Condition #15: Met

Resolution: Corrected: 2023-08-01

5 of 5 child files did not have dental visit scheduled.

Resolution: Corrected: 2023-08-08

Abuse/Neglect investigation reported two staff members did not provide adequate medical care for a child in care.

Resolution: Corrected: 2023-10-16

Abuse/Neglect investigation reported two staff members did not provide adequate medical care for a child in care.

Resolution: Corrected: 2023-10-16

Record for daily insulin dosages were not documented in the medication log

Resolution: Corrected: 2023-10-19

Child?s preliminary service plan does not describe how the operation will meet the child?s medical needs or follow-up plan for possible side effects.

Resolution: Corrected: 2023-10-19

Child?s preliminary service plan did not include self medication protocols for child and staff members to ensure the child?s health and safety.

Resolution: Corrected: 2023-10-19

Abuse/Neglect investigation reported two staff members did not provide adequate medical care for a child in care.

Resolution: Corrected: 2023-10-16

Record for daily insulin dosages were not documented in the medication log

Resolution: Corrected: 2023-10-19

Child?s preliminary service plan does not describe how the operation will meet the child?s medical needs or follow-up plan for possible side effects.

Resolution: Corrected: 2023-10-19

Child?s preliminary service plan did not include self medication protocols for child and staff members to ensure the child?s health and safety.

Resolution: Corrected: 2023-10-19

Child?s preliminary service plan does not describe how the operation will meet the child?s medical needs or follow-up plan for possible side effects.

Resolution: Corrected: 2023-10-19

Record for daily insulin dosages were not documented in the medication log

Resolution: Corrected: 2023-10-19

Child?s preliminary service plan did not include self medication protocols for child and staff members to ensure the child?s health and safety.

Resolution: Corrected: 2023-10-19

Discharge documentation did not discuss when the child was informed of discharge or transfer.

Resolution: Corrected: 2023-08-24

Discharge documentation did not discuss when the child was informed of discharge or transfer.

Resolution: Corrected: 2023-08-24

Discharge documentation did not discuss when the child was informed of discharge or transfer.

Resolution: Corrected: 2023-08-24

One caregiver was responsible for eight children when a physical altercation broke out between two children in care.

Resolution: Corrected: 2023-08-03

One caregiver was responsible for eight children when a physical altercation broke out between two children in care.

Resolution: Corrected: 2023-08-03

One caregiver was responsible for eight children when a physical altercation broke out between two children in care.

Resolution: Corrected: 2023-08-03

Employee who has not completed medication administration training has given medication to a child in care.

Resolution: Corrected: 2023-06-27

4 of 4 medication logs were missing the medication pill count.

Resolution: Corrected: 2023-06-27

Condition # 1: Pending - extention granted to 7/10/23. Condition #2: Met Condition #3: Not Met - operation did not complete a new comprehensive assessment for a rehired employee Condition #4: Met Condition #5: Met Condition #6: Not Met - Employee administered medication before completing medication training requirement per the condition Condition #7: Met Condition #8: Met Condition #9: Met Condition #10: Met Condition #11: Met Condition #12: Met Condition #13: Not Met - Operation is not completing audit of child files at admission. The operation is not completing audit of children files per the requirement of this condition. Condition #14: Met Condition #15: Not Met - operation did not provide documentation to RCCI in a timely manner. This is in reference to INV#49478617.

Resolution: Corrected: 2023-07-10

Employee who has not completed medication administration training has given medication to a child in care.

Resolution: Corrected: 2023-06-27

An employee is present at the operation with an inactive background check status.

Resolution: Corrected: 2023-06-23

3 of 4 child files reviewed had missing medication dosages.

Resolution: Corrected: 2023-06-23

4 of 4 mediaction files were missing prescribing health-care professional's name as well as reason for medication.

Resolution: Corrected: 2023-06-27

Condition # 1: Pending - extention granted to 7/10/23. Condition #2: Met Condition #3: Not Met - operation did not complete a new comprehensive assessment for a rehired employee Condition #4: Met Condition #5: Met Condition #6: Not Met - Employee administered medication before completing medication training requirement per the condition Condition #7: Met Condition #8: Met Condition #9: Met Condition #10: Met Condition #11: Met Condition #12: Met Condition #13: Not Met - Operation is not completing audit of child files at admission. The operation is not completing audit of children files per the requirement of this condition. Condition #14: Met Condition #15: Not Met - operation did not provide documentation to RCCI in a timely manner. This is in reference to INV#49478617.

Resolution: Corrected: 2023-07-10

3 of 4 child files reviewed had missing medication dosages.

Resolution: Corrected: 2023-06-23

4 of 4 medication logs were missing the medication pill count.

Resolution: Corrected: 2023-06-27

An employee is present at the operation with an inactive background check status.

Resolution: Corrected: 2023-06-23

4 of 4 mediaction files were missing prescribing health-care professional's name as well as reason for medication.

Resolution: Corrected: 2023-06-27

Condition # 1: Pending - extention granted to 7/10/23. Condition #2: Met Condition #3: Not Met - operation did not complete a new comprehensive assessment for a rehired employee Condition #4: Met Condition #5: Met Condition #6: Not Met - Employee administered medication before completing medication training requirement per the condition Condition #7: Met Condition #8: Met Condition #9: Met Condition #10: Met Condition #11: Met Condition #12: Met Condition #13: Not Met - Operation is not completing audit of child files at admission. The operation is not completing audit of children files per the requirement of this condition. Condition #14: Met Condition #15: Not Met - operation did not provide documentation to RCCI in a timely manner. This is in reference to INV#49478617.

Resolution: Corrected: 2023-07-10

3 of 4 child files reviewed had missing medication dosages.

Resolution: Corrected: 2023-06-23

Employee who has not completed medication administration training has given medication to a child in care.

Resolution: Corrected: 2023-06-27

4 of 4 medication logs were missing the medication pill count.

Resolution: Corrected: 2023-06-27

An employee is present at the operation with an inactive background check status.

Resolution: Corrected: 2023-06-23

4 of 4 mediaction files were missing prescribing health-care professional's name as well as reason for medication.

Resolution: Corrected: 2023-06-27

On June 13th a child was provided a mental health assessment due to a suicide attempt. The child was then hospitalized for treatment. The incident was not reported to Licensing until 3 days later. The incident was not documented as a serious incident.

Resolution: Corrected: 2023-08-03

On June 13th a child was provided a mental health assessment due to a suicide attempt. The child was then hospitalized for treatment. The incident was not reported to Licensing until 3 days later. The incident was not documented as a serious incident.

Resolution: Corrected: 2023-08-03

On June 13th a child was provided a mental health assessment due to a suicide attempt. The child was then hospitalized for treatment. The incident was not reported to Licensing until 3 days later. The incident was not documented as a serious incident.

Resolution: Corrected: 2023-08-03

The operation documents a serious incident report as a incident report.

Resolution: Corrected: 2023-09-07

The operation documents a serious incident report as a incident report.

Resolution: Corrected: 2023-09-07

A child in care was left unsupervised during a one-on-one supervision resulting in suicide attempt.

Resolution: Corrected: 2023-09-07

The operation documents a serious incident report as a incident report.

Resolution: Corrected: 2023-09-07

A child in care was left unsupervised during a one-on-one supervision resulting in suicide attempt.

Resolution: Corrected: 2023-09-07

A child in care was left unsupervised during a one-on-one supervision resulting in suicide attempt.

Resolution: Corrected: 2023-09-07

A child in care attempted suicide and the operation did not document the how the parent was notified.

Resolution: Corrected: 2023-06-29

A child in care attempted suicide and the operation did not document the how the parent was notified.

Resolution: Corrected: 2023-06-29

A child in care attempted suicide and the operation did not document the how the parent was notified.

Resolution: Corrected: 2023-06-29

Youth-in-care did not receive a new Suicide Full Assessment when admitted to care.

Resolution: Corrected: 2023-07-25

In reviewing the admission assessment, youth-in-care assessment of suicide potential was high and intervention plan was not properly implemented.

Resolution: Corrected: 2023-07-25

In reviewing the admission assessment, youth-in-care assessment of suicide potential was high and intervention plan was not properly implemented.

Resolution: Corrected: 2023-07-25

Youth-in-care did not receive a new Suicide Full Assessment when admitted to care.

Resolution: Corrected: 2023-07-25

Youth-in-care did not receive a new Suicide Full Assessment when admitted to care.

Resolution: Corrected: 2023-07-25

In reviewing the admission assessment, youth-in-care assessment of suicide potential was high and intervention plan was not properly implemented.

Resolution: Corrected: 2023-07-25

3 medication files were observed to not have legal guardian signature for psychotrophic medication consent.

Resolution: Corrected: 2023-05-30

3 medication files were observed to not have legal guardian signature for psychotrophic medication consent.

Resolution: Corrected: 2023-05-30

3 medication files were observed to not have legal guardian signature for psychotrophic medication consent.

Resolution: Corrected: 2023-05-30

Condition #1: The program evaluation submitted is a check list, that provides rating of each criterion. It does not provide information to the reader on how each determination was made. Condition #2: Met Condition #3: Met Condition #4: Met Condition #5: Met Condition #6: Medication policies state a specified person will administer medication, medication file was observed to have multiple nurses administer medication to a child in care. Condition #7: Met Condition #8: Met Condition #9: Met Condition #10: Met Condition #11: Met Condition #12: Met Condition #13:This condition is considered not met because the date of correction is not being documented on the audit form. Condition #14: Met Condition #15: Met

Resolution: Corrected: 2023-06-08

Condition #1: The program evaluation submitted is a check list, that provides rating of each criterion. It does not provide information to the reader on how each determination was made. Condition #2: Met Condition #3: Met Condition #4: Met Condition #5: Met Condition #6: Medication policies state a specified person will administer medication, medication file was observed to have multiple nurses administer medication to a child in care. Condition #7: Met Condition #8: Met Condition #9: Met Condition #10: Met Condition #11: Met Condition #12: Met Condition #13:This condition is considered not met because the date of correction is not being documented on the audit form. Condition #14: Met Condition #15: Met

Resolution: Corrected: 2023-06-08

Condition #1: The program evaluation submitted is a check list, that provides rating of each criterion. It does not provide information to the reader on how each determination was made. Condition #2: Met Condition #3: Met Condition #4: Met Condition #5: Met Condition #6: Medication policies state a specified person will administer medication, medication file was observed to have multiple nurses administer medication to a child in care. Condition #7: Met Condition #8: Met Condition #9: Met Condition #10: Met Condition #11: Met Condition #12: Met Condition #13:This condition is considered not met because the date of correction is not being documented on the audit form. Condition #14: Met Condition #15: Met

Resolution: Corrected: 2023-06-08

Clinical Progress Logs documents that children were observed by staff members when they were not.

Resolution: Corrected: 2023-06-26

Clinical Progress Logs documents that children were observed by staff members when they were not.

Resolution: Corrected: 2023-06-26

Treatment plans indicated that children must be observed every 15 minutes by staff members. These instructions were not followed.

Resolution: Corrected: 2023-06-26

During sleeping hours, a child in care entered multiple rooms several times without staff's knowledge.

Resolution: Corrected: 2023-06-26

Clinical Progress Logs documents that children were observed by staff members when they were not.

Resolution: Corrected: 2023-06-26

Treatment plans indicated that children must be observed every 15 minutes by staff members. These instructions were not followed.

Resolution: Corrected: 2023-06-26

During sleeping hours, a child in care entered multiple rooms several times without staff's knowledge.

Resolution: Corrected: 2023-06-26

Treatment plans indicated that children must be observed every 15 minutes by staff members. These instructions were not followed.

Resolution: Corrected: 2023-06-26

During sleeping hours, a child in care entered multiple rooms several times without staff's knowledge.

Resolution: Corrected: 2023-06-26

2 service plans reviewed were not completed in 72 hours.

Resolution: Corrected: 2023-05-05

2 service plans reviewed were not completed in 72 hours.

Resolution: Corrected: 2023-05-05

2 service plans reviewed were not completed in 72 hours.

Resolution: Corrected: 2023-05-05

An incident report completed five days after the incident occurred did not include a description of the incident.

Resolution: Corrected: 2023-06-23

The operation failed to notify Licensing within 24 hours of a child in care being transported by EMS for emergent medical care.

Resolution: Corrected: 2023-06-23

The operation failed to notify Licensing within 24 hours of a child in care being transported by EMS for emergent medical care.

Resolution: Corrected: 2023-06-23

An incident report completed five days after the incident occurred did not include a description of the incident.

Resolution: Corrected: 2023-06-23

An incident report completed five days after the incident occurred did not include a description of the incident.

Resolution: Corrected: 2023-06-23

The operation failed to notify Licensing within 24 hours of a child in care being transported by EMS for emergent medical care.

Resolution: Corrected: 2023-06-23

A restraint that lasted 3 to 5 minutes was not documented.

Resolution: Corrected: 2023-07-20

A restraint that lasted 3 to 5 minutes was not documented.

Resolution: Corrected: 2023-07-20

A restraint that lasted 3 to 5 minutes was not documented.

Resolution: Corrected: 2023-07-20

5 Medication logs did not have a pill count or inventory listed.

Resolution: Corrected: 2023-04-26

5 Medication logs did not have prescribing doctor listed.

Resolution: Corrected: 2023-04-26

2 service plans reviewed were not completed in 72 hours.

Resolution: Corrected at inspection

5 Medication logs did not have a pill count or inventory listed.

Resolution: Corrected: 2023-04-26

5 out 15 probation conditions were not met. Condition #1: Met Condition #2: Met Condition #3: Met Condition #4: Met Condition #5: Met Condition #6: Met Condition #7: the training was not due per conditions. Condition #8: Did not meet - trainings not completed with all staff by the due date of 4/12/2023; Condition #9: Did not meet - 18 staff members did not complete trainings by 03/26/2023; Condition #10: Did not meet - 13 staff members trainings were not completed by 3/26/2023; Condition #11: Met Condition #12: Met Condition #13: Met Condition #14: Did not meet - one child file did not have parent notification; Condition #15: Met

Resolution: Corrected: 2023-05-03

2 service plans reviewed were not completed in 72 hours.

Resolution: Corrected at inspection

3 medication logs show medication was taken without a stated reason.

Resolution: Corrected: 2023-04-26

5 out 15 probation conditions were not met. Condition #1: Met Condition #2: Met Condition #3: Met Condition #4: Met Condition #5: Met Condition #6: Met Condition #7: the training was not due per conditions. Condition #8: Did not meet - trainings not completed with all staff by the due date of 4/12/2023; Condition #9: Did not meet - 18 staff members did not complete trainings by 03/26/2023; Condition #10: Did not meet - 13 staff members trainings were not completed by 3/26/2023; Condition #11: Met Condition #12: Met Condition #13: Met Condition #14: Did not meet - one child file did not have parent notification; Condition #15: Met

Resolution: Corrected: 2023-05-03

5 out 15 probation conditions were not met. Condition #1: Met Condition #2: Met Condition #3: Met Condition #4: Met Condition #5: Met Condition #6: Met Condition #7: the training was not due per conditions. Condition #8: Did not meet - trainings not completed with all staff by the due date of 4/12/2023; Condition #9: Did not meet - 18 staff members did not complete trainings by 03/26/2023; Condition #10: Did not meet - 13 staff members trainings were not completed by 3/26/2023; Condition #11: Met Condition #12: Met Condition #13: Met Condition #14: Did not meet - one child file did not have parent notification; Condition #15: Met

Resolution: Corrected: 2023-05-03

2 service plans reviewed were not completed in 72 hours.

Resolution: Corrected at inspection

5 Medication logs did not have prescribing doctor listed.

Resolution: Corrected: 2023-04-26

5 Medication logs did not have a pill count or inventory listed.

Resolution: Corrected: 2023-04-26

3 medication logs show medication was taken without a stated reason.

Resolution: Corrected: 2023-04-26

3 medication logs show medication was taken without a stated reason.

Resolution: Corrected: 2023-04-26

5 Medication logs did not have prescribing doctor listed.

Resolution: Corrected: 2023-04-26

A caregiver failed to abide by a child's supervision requirements which resulted in a suicide attempt.

Resolution: Corrected: 2023-05-31

A child's suicide attempt was not reported as required by minimum standards.

Resolution: Corrected: 2023-05-31

A child placed a bag over the head with the intent to harm himself. The child was not properly assessed for safety after this incident by the operation as required by Minimum Standards.

Resolution: Corrected: 2023-05-31

A caregiver failed to abide by a child's supervision requirements which resulted in a suicide attempt.

Resolution: Corrected: 2023-05-31

A child's suicide attempt was not reported as required by minimum standards.

Resolution: Corrected: 2023-05-31

A caregiver failed to abide by a child's supervision requirements which resulted in a suicide attempt.

Resolution: Corrected: 2023-05-31

A child's suicide attempt was not reported as required by minimum standards.

Resolution: Corrected: 2023-05-31

A child placed a bag over the head with the intent to harm himself. The child was not properly assessed for safety after this incident by the operation as required by Minimum Standards.

Resolution: Corrected: 2023-05-31

A child placed a bag over the head with the intent to harm himself. The child was not properly assessed for safety after this incident by the operation as required by Minimum Standards.

Resolution: Corrected: 2023-05-31

Staff conducted a restraint of a child where the child was lifted off their feet and taken to the floor. The child sustained an injury to the hand.

Resolution: Corrected: 2023-04-21

Staff conducted a restraint of a child where the child was lifted off their feet and taken to the floor. The child sustained an injury to the hand.

Resolution: Corrected: 2023-04-21

Children in care were allowed to remain in the same proximity when child restraints were performed.

Resolution: Corrected: 2023-04-21

Child in care was restrained after staff demonstrated behavior that escalated the child. Staff did not engage in appropriate de-escalation techniques.

Resolution: Corrected: 2023-04-21

Staff conducted a restraint of a child where the child was lifted off their feet and taken to the floor. The child sustained an injury to the hand.

Resolution: Corrected: 2023-04-21

Child in care was restrained after staff demonstrated behavior that escalated the child. Staff did not engage in appropriate de-escalation techniques.

Resolution: Corrected: 2023-04-21

Children in care were allowed to remain in the same proximity when child restraints were performed.

Resolution: Corrected: 2023-04-21

Children in care were allowed to remain in the same proximity when child restraints were performed.

Resolution: Corrected: 2023-04-21

Child in care was restrained after staff demonstrated behavior that escalated the child. Staff did not engage in appropriate de-escalation techniques.

Resolution: Corrected: 2023-04-21

A caregiver implemented a personal restraint, prior to being trained in EBI.

Resolution: Corrected: 2023-04-04

A child in care was placed in a supine restraint for several minutes. There was no indication that this position was the most effective technique.

Resolution: Corrected: 2023-04-04

A restraint was implemented on 02/07/2023. The documentation of the restraint is incongruent with what was observed on the video.

Resolution: Corrected: 2023-04-04

A child in care was under the influence of a substance, was behaving abnormally, and was not separated from the group during therapy.

Resolution: Corrected: 2023-04-04

A caregiver implemented a personal restraint, prior to being trained in EBI.

Resolution: Corrected: 2023-04-04

A child in care was placed in a supine restraint for several minutes. There was no indication that this position was the most effective technique.

Resolution: Corrected: 2023-04-04

A restraint was implemented on 02/07/2023. The documentation of the restraint is incongruent with what was observed on the video.

Resolution: Corrected: 2023-04-04

A child in care was under the influence of a substance, was behaving abnormally, and was not separated from the group during therapy.

Resolution: Corrected: 2023-04-04

A child in care was under the influence of a substance, was behaving abnormally, and was not separated from the group during therapy.

Resolution: Corrected: 2023-04-04

A child in care was placed in a supine restraint for several minutes. There was no indication that this position was the most effective technique.

Resolution: Corrected: 2023-04-04

A caregiver implemented a personal restraint, prior to being trained in EBI.

Resolution: Corrected: 2023-04-04

A restraint was implemented on 02/07/2023. The documentation of the restraint is incongruent with what was observed on the video.

Resolution: Corrected: 2023-04-04

An admissions assessment completed on 01/21/23 documents that a child was abused. The information was not reported as required.

Resolution: Corrected: 2023-03-03

1 of 1 medication log did not provide a reason medication was prescribed.

Resolution: Corrected: 2023-03-03

An admissions assessment completed on 01/21/23 documents that a child was abused. The information was not reported as required.

Resolution: Corrected: 2023-03-03

1 of 1 medication log did not provide a reason medication was prescribed.

Resolution: Corrected: 2023-03-03

An admissions assessment completed on 01/21/23 documents that a child was abused. The information was not reported as required.

Resolution: Corrected: 2023-03-03

1 of 1 medication log did not provide a reason medication was prescribed.

Resolution: Corrected: 2023-03-03

Operation did not allow children to be interviewed as part of an investigation.

Resolution: Corrected: 2023-01-25

Operation did not allow children to be interviewed as part of an investigation.

Resolution: Corrected: 2023-01-25

Operation did not allow children to be interviewed as part of an investigation.

Resolution: Corrected: 2023-01-25

A child in care was reported missing on 12/15/22, 12/16/22, and 12/21/22. The child returned after 12/21/22. A trigger review was not completed.

Resolution: Corrected: 2023-04-01

A child was reported absent 3 times to statewide intake. The child's name was not recorded on the unauthorized absence report.

Resolution: Corrected: 2023-02-09

Several employee files did not contain verification for how job requirements were met. 1 employee's resume and degree was emailed to support verification after the inspection was complete.

Resolution: Corrected: 2023-04-01

An employee with an inactive background check was on property at the time of the inspection.

Resolution: Corrected at inspection

A child in care was reported missing on 12/15/22, 12/16/22, and 12/21/22. The child returned after 12/21/22. A trigger review was not completed.

Resolution: Corrected: 2023-04-01

The 6 month's unauthorized absence evaluation was requested at inspections conducted on 01/18/23 and 01/24/23. This document was not provided.

Resolution: Corrected: 2023-02-09

An employee with an inactive background check was on property at the time of the inspection.

Resolution: Corrected at inspection

Several employee files did not contain verification for how job requirements were met. 1 employee's resume and degree was emailed to support verification after the inspection was complete.

Resolution: Corrected: 2023-04-01

EBI training for SAMA began as of 12/29/22. This technique was not submitted for approval prior to implementation.

Resolution: Corrected: 2023-02-09

A child was reported absent 3 times to statewide intake. The child's name was not recorded on the unauthorized absence report.

Resolution: Corrected: 2023-02-09

A child in care was reported missing on 12/15/22, 12/16/22, and 12/21/22. The child returned after 12/21/22. A trigger review was not completed.

Resolution: Corrected: 2023-04-01

The 6 month's unauthorized absence evaluation was requested at inspections conducted on 01/18/23 and 01/24/23. This document was not provided.

Resolution: Corrected: 2023-02-09

An employee with an inactive background check was on property at the time of the inspection.

Resolution: Corrected at inspection

Several employee files did not contain verification for how job requirements were met. 1 employee's resume and degree was emailed to support verification after the inspection was complete.

Resolution: Corrected: 2023-04-01

EBI training for SAMA began as of 12/29/22. This technique was not submitted for approval prior to implementation.

Resolution: Corrected: 2023-02-09

A child was reported absent 3 times to statewide intake. The child's name was not recorded on the unauthorized absence report.

Resolution: Corrected: 2023-02-09

The 6 month's unauthorized absence evaluation was requested at inspections conducted on 01/18/23 and 01/24/23. This document was not provided.

Resolution: Corrected: 2023-02-09

EBI training for SAMA began as of 12/29/22. This technique was not submitted for approval prior to implementation.

Resolution: Corrected: 2023-02-09

2 of 15 employee records did not have sign statements to abide by this rule.

Resolution: Corrected: 2023-04-01

2 nursing staff files did not contain a license.

Resolution: Corrected: 2023-04-01

2 of 15 employee records did not have sign statements to abide by this rule.

Resolution: Corrected: 2023-04-01

A licensed professional was not involved in the development of 1 child's service plan. The child was identified to receive treatment services for emotional disorders.

Resolution: Corrected: 2023-04-01

11 of the 15 records reviewed did not meet the requirement. Specifically, 4 affidavits were incomplete, and 7 affidavits were not notarized or were missing from the record.

Resolution: Corrected: 2023-04-01

8 of 15 employee files were missing TB exams.

Resolution: Corrected: 2023-04-01

13 employee records did not contain education and/or CPR and First Aid verification as required by the job description.

Resolution: Corrected: 2023-04-01

A care coordinator/caregiver was not involved in the development of 1 child's service plan. The child was not identified to receive treatment services.

Resolution: Corrected: 2023-03-24

6 caregivers did not have information to support receiving training prior to performing assigned work duties.

Resolution: Corrected: 2023-04-01

A care coordinator/caregiver was not involved in the development of 1 child's service plan. The child was not identified to receive treatment services.

Resolution: Corrected: 2023-03-24

Staff members were made inactive as of 12/05/22 and 01/13/23. The reason for their separations was not found in the employee record.

Resolution: Corrected: 2023-04-01

7 out of 15 employee records were missing job descriptions.

Resolution: Corrected: 2023-04-01

A child placed on 12/02/22 did not have a completed service plan as of inspection date 1/18/23.

Resolution: Corrected at inspection

2 of the 15 files reviewed did not contain a record of training taken by the employee.

Resolution: Corrected: 2023-04-01

3 of 15 files did not contain background check request information.

Resolution: Corrected: 2023-04-01

A child's record filed a medication log that did not record the reason for the medication, the prescriber's name, or the person who administered the medication.

Resolution: Corrected: 2023-03-24

A child placed on 12/02/22 did not have a completed service plan as of inspection date 1/18/23.

Resolution: Corrected at inspection

7 out of 15 employee records were missing job descriptions.

Resolution: Corrected: 2023-04-01

Staff members were made inactive as of 12/05/22 and 01/13/23. The reason for their separations was not found in the employee record.

Resolution: Corrected: 2023-04-01

A licensed professional was not involved in the development of 1 child's service plan. The child was identified to receive treatment services for emotional disorders.

Resolution: Corrected: 2023-04-01

2 of 15 employee records did not have sign statements to abide by this rule.

Resolution: Corrected: 2023-04-01

2 nursing staff files did not contain a license.

Resolution: Corrected: 2023-04-01

7 out of 15 employee records were missing job descriptions.

Resolution: Corrected: 2023-04-01

13 employee records did not contain education and/or CPR and First Aid verification as required by the job description.

Resolution: Corrected: 2023-04-01

2 of the 15 files reviewed did not contain a record of training taken by the employee.

Resolution: Corrected: 2023-04-01

6 caregivers did not have information to support receiving training prior to performing assigned work duties.

Resolution: Corrected: 2023-04-01

11 of the 15 records reviewed did not meet the requirement. Specifically, 4 affidavits were incomplete, and 7 affidavits were not notarized or were missing from the record.

Resolution: Corrected: 2023-04-01

8 of 15 employee files were missing TB exams.

Resolution: Corrected: 2023-04-01

Staff members were made inactive as of 12/05/22 and 01/13/23. The reason for their separations was not found in the employee record.

Resolution: Corrected: 2023-04-01

3 of 15 files did not contain background check request information.

Resolution: Corrected: 2023-04-01

A care coordinator/caregiver was not involved in the development of 1 child's service plan. The child was not identified to receive treatment services.

Resolution: Corrected: 2023-03-24

A child placed on 12/02/22 did not have a completed service plan as of inspection date 1/18/23.

Resolution: Corrected at inspection

A child's record filed a medication log that did not record the reason for the medication, the prescriber's name, or the person who administered the medication.

Resolution: Corrected: 2023-03-24

2 of the 15 files reviewed did not contain a record of training taken by the employee.

Resolution: Corrected: 2023-04-01

2 nursing staff files did not contain a license.

Resolution: Corrected: 2023-04-01

3 of 15 files did not contain background check request information.

Resolution: Corrected: 2023-04-01

A child's record filed a medication log that did not record the reason for the medication, the prescriber's name, or the person who administered the medication.

Resolution: Corrected: 2023-03-24

6 caregivers did not have information to support receiving training prior to performing assigned work duties.

Resolution: Corrected: 2023-04-01

13 employee records did not contain education and/or CPR and First Aid verification as required by the job description.

Resolution: Corrected: 2023-04-01

8 of 15 employee files were missing TB exams.

Resolution: Corrected: 2023-04-01

11 of the 15 records reviewed did not meet the requirement. Specifically, 4 affidavits were incomplete, and 7 affidavits were not notarized or were missing from the record.

Resolution: Corrected: 2023-04-01

A licensed professional was not involved in the development of 1 child's service plan. The child was identified to receive treatment services for emotional disorders.

Resolution: Corrected: 2023-04-01

The operation did not provide the videos requested by the Investigator pertaining to a particular employee.

Resolution: Corrected: 2023-04-01

A child in care used facetime to contact an unknown male often. When the behavior was identified, follow up actions were not implemented to ensure child safety.

Resolution: Corrected: 2023-10-17

A caregiver engaged in an inappropriate relationship and did not maintain appropriate boundaries when engaging children in care.

Resolution: Corrected: 2023-10-17

A caregiver solicited images, videos, and encouraged sexualized activities from a 13, 16, and 17 year old children in care.

Resolution: Corrected: 2023-10-17

A child in care used facetime to contact an unknown male often. When the behavior was identified, follow up actions were not implemented to ensure child safety.

Resolution: Corrected: 2023-10-17

The operation did not provide the videos requested by the Investigator pertaining to a particular employee.

Resolution: Corrected: 2023-04-01

A caregiver engaged in an inappropriate relationship and did not maintain appropriate boundaries when engaging children in care.

Resolution: Corrected: 2023-10-17

A caregiver solicited images, videos, and encouraged sexualized activities from a 13, 16, and 17 year old children in care.

Resolution: Corrected: 2023-10-17

A child in care used facetime to contact an unknown male often. When the behavior was identified, follow up actions were not implemented to ensure child safety.

Resolution: Corrected: 2023-10-17

A caregiver engaged in an inappropriate relationship and did not maintain appropriate boundaries when engaging children in care.

Resolution: Corrected: 2023-10-17

A caregiver solicited images, videos, and encouraged sexualized activities from a 13, 16, and 17 year old children in care.

Resolution: Corrected: 2023-10-17

The operation did not provide the videos requested by the Investigator pertaining to a particular employee.

Resolution: Corrected: 2023-04-01

Concerns of abuse of a child in care by was not reported within timeframes.

Resolution: Corrected: 2023-03-10

Child was observed to have redness to the armpit area and seen by the facility nurse. The medical encounter was not documented as required on an incident report.

Resolution: Corrected: 2023-03-10

Concerns of abuse of a child in care by was not reported within timeframes.

Resolution: Corrected: 2023-03-10

Concerns of abuse of a child in care by was not reported within timeframes.

Resolution: Corrected: 2023-03-10

Child was observed to have redness to the armpit area and seen by the facility nurse. The medical encounter was not documented as required on an incident report.

Resolution: Corrected: 2023-03-10

Child was observed to have redness to the armpit area and seen by the facility nurse. The medical encounter was not documented as required on an incident report.

Resolution: Corrected: 2023-03-10

Caregivers were notified of allegations regarding staff behaviors that posed a risk to children in care. The staff did not take any action to reduce risk to the children and provide a safe environment.

Resolution: Corrected: 2023-04-01

A staff member engaged in tickling, touching, and hugging of children in care without consent. The staff member's actions were indicated to make children uncomfortable.

Resolution: Corrected: 2023-04-01

A staff member engaged in tickling, touching, and hugging of children in care without consent. The staff member's actions were indicated to make children uncomfortable.

Resolution: Corrected: 2023-04-01

Caregivers were notified of allegations regarding staff behaviors that posed a risk to children in care. The staff did not take any action to reduce risk to the children and provide a safe environment.

Resolution: Corrected: 2023-04-01

Multiple staff members were informed of an allegation of a staff member touching children in care and did not report the allegation as required.

Resolution: Corrected: 2023-04-01

A staff member engaged in tickling, touching, and hugging of children in care without consent. The staff member's actions were indicated to make children uncomfortable.

Resolution: Corrected: 2023-04-01

Caregivers were notified of allegations regarding staff behaviors that posed a risk to children in care. The staff did not take any action to reduce risk to the children and provide a safe environment.

Resolution: Corrected: 2023-04-01

Multiple staff members were informed of an allegation of a staff member touching children in care and did not report the allegation as required.

Resolution: Corrected: 2023-04-01

Multiple staff members were informed of an allegation of a staff member touching children in care and did not report the allegation as required.

Resolution: Corrected: 2023-04-01

The service plan for the youth documented a general statement for supervision and did not discuss his employment or the specific needs of the youth.

Resolution: Corrected: 2023-02-20

The service plan for the youth documented a general statement for supervision and did not discuss his employment or the specific needs of the youth.

Resolution: Corrected: 2023-02-20

A youth's job was threatened by a staff member as discipline.

Resolution: Corrected: 2023-02-20

A youth's job was threatened by a staff member as discipline.

Resolution: Corrected: 2023-02-20

The service plan for the youth documented a general statement for supervision and did not discuss his employment or the specific needs of the youth.

Resolution: Corrected: 2023-02-20

A youth's job was threatened by a staff member as discipline.

Resolution: Corrected: 2023-02-20

The service plan was not signed by any of the team members.

Resolution: Corrected: 2023-03-14

The service plan was not signed by any of the team members.

Resolution: Corrected: 2023-03-14

The service plan was not signed by any of the team members.

Resolution: Corrected: 2023-03-14

An employee was named as the Treatment Director for children with Autism Spectrum Disorder. The employee did not meet the requirement of this rule.

Resolution: Corrected: 2023-04-01

A Treatment Director was named as providing services to children with Emotional Disorders. The person identified did not meet the qualifications of this rule.

Resolution: Corrected: 2023-04-01

A contracted mental health professional documented in a child's file that a child was "jumped" by other children in care. The professional described the physical injuries observed. The operation did not report this incident to Regulations.

Resolution: Corrected: 2023-03-02

37 children were in placement. Of the 37 children placed 14 children were receiving services for emotional disorders (38%). At the time of the inspection, the Treatment Directors named did not meet the rule requirement.

Resolution: Corrected: 2023-04-01

An employee was named as the Treatment Director for children with Autism Spectrum Disorder. The employee did not meet the requirement of this rule.

Resolution: Corrected: 2023-04-01

The annual log was provided and two children in care who ran away for the facility was not listed.

Resolution: Corrected: 2023-02-27

A contracted mental health professional documented in a child's file that a child was "jumped" by other children in care. The professional described the physical injuries observed. The operation did not report this incident to Regulations.

Resolution: Corrected: 2023-03-02

37 children were in placement. Of the 37 children placed 14 children were receiving services for emotional disorders (38%). At the time of the inspection, the Treatment Directors named did not meet the rule requirement.

Resolution: Corrected: 2023-04-01

A Treatment Director was named as providing services to children with Emotional Disorders. The person identified did not meet the qualifications of this rule.

Resolution: Corrected: 2023-04-01

The annual log was provided and two children in care who ran away for the facility was not listed.

Resolution: Corrected: 2023-02-27

An employee was named as the Treatment Director for children with Autism Spectrum Disorder. The employee did not meet the requirement of this rule.

Resolution: Corrected: 2023-04-01

A contracted mental health professional documented in a child's file that a child was "jumped" by other children in care. The professional described the physical injuries observed. The operation did not report this incident to Regulations.

Resolution: Corrected: 2023-03-02

37 children were in placement. Of the 37 children placed 14 children were receiving services for emotional disorders (38%). At the time of the inspection, the Treatment Directors named did not meet the rule requirement.

Resolution: Corrected: 2023-04-01

A Treatment Director was named as providing services to children with Emotional Disorders. The person identified did not meet the qualifications of this rule.

Resolution: Corrected: 2023-04-01

The annual log was provided and two children in care who ran away for the facility was not listed.

Resolution: Corrected: 2023-02-27

A staff member pushed a child against a wall as a form of discipline.

Resolution: Corrected: 2023-01-24

A child in care was allowed to remain in the same area during an incident involving multiple restraints of another child.

Resolution: Corrected: 2023-01-27

A child in care was allowed to remain in the same area during an incident involving multiple restraints of another child.

Resolution: Corrected: 2023-01-27

A staff member pushed a child against a wall as a form of discipline.

Resolution: Corrected: 2023-01-24

A child was restrained multiple times in a day, with 6 or 7 staff members surrounding the child, escalating the situation.

Resolution: Corrected: 2023-01-27

Two caregivers held a child's arms behind her back as a form of restraint.

Resolution: Corrected: 2023-01-27

A child was restrained multiple times in a day, with 6 or 7 staff members surrounding the child, escalating the situation.

Resolution: Corrected: 2023-01-27

Two caregivers held a child's arms behind her back as a form of restraint.

Resolution: Corrected: 2023-01-27

A staff member pushed a child against a wall as a form of discipline.

Resolution: Corrected: 2023-01-24

A child was restrained multiple times in a day, with 6 or 7 staff members surrounding the child, escalating the situation.

Resolution: Corrected: 2023-01-27

Two caregivers held a child's arms behind her back as a form of restraint.

Resolution: Corrected: 2023-01-27

A child in care was allowed to remain in the same area during an incident involving multiple restraints of another child.

Resolution: Corrected: 2023-01-27

Children in care were allowed to have personal cell phone devices. This process was not according to policy.

Resolution: Corrected: 2023-02-15

Children in care were allowed to have personal cell phone devices. This process was not according to policy.

Resolution: Corrected: 2023-02-15

Children in care were allowed to have personal cell phone devices. This process was not according to policy.

Resolution: Corrected: 2023-02-15

The admission assessment did not include the child's legal status.

Resolution: Corrected: 2023-02-08

The admission assessment did not include the child's legal status.

Resolution: Corrected: 2023-02-08

The admission assessment did not include the child's legal status.

Resolution: Corrected: 2023-02-08

A staff member physically fought with a child and had to be held back by another staff to stop the conflict.

Resolution: Corrected: 2023-01-27

A staff member yelled at a child in care.

Resolution: Corrected: 2023-01-27

A group of children were allowed to remain in the same area during a physical incident involving a staff member and another child and a subsequent restraint.

Resolution: Corrected: 2023-03-03

A staff member yelled at a child in care.

Resolution: Corrected: 2023-01-27

A group of children were allowed to remain in the same area during a physical incident involving a staff member and another child and a subsequent restraint.

Resolution: Corrected: 2023-03-03

A staff member physically fought with a child and had to be held back by another staff to stop the conflict.

Resolution: Corrected: 2023-01-27

A staff member yelled at a child in care.

Resolution: Corrected: 2023-01-27

A group of children were allowed to remain in the same area during a physical incident involving a staff member and another child and a subsequent restraint.

Resolution: Corrected: 2023-03-03

A staff member physically fought with a child and had to be held back by another staff to stop the conflict.

Resolution: Corrected: 2023-01-27

There is a video footage of a child leaving the cafeteria to attack another child at the facility. There were two staff standing in the doorway and did not intervene.

Resolution: Corrected: 2023-02-24

There is a video footage of a child leaving the cafeteria to attack another child at the facility. There were two staff standing in the doorway and did not intervene.

Resolution: Corrected: 2023-02-24

There is a video footage of a child leaving the cafeteria to attack another child at the facility. There were two staff standing in the doorway and did not intervene.

Resolution: Corrected: 2023-02-24

There was one bathroom that had a hole in the wall.

Resolution: Corrected: 2022-12-08

There was one bathroom that had a hole in the wall.

Resolution: Corrected: 2022-12-08

There was one bathroom that had a hole in the wall.

Resolution: Corrected: 2022-12-08

The operation has two staff who were shadowing a staff person who did not have current background checks. There were also four employees who were working and had inactive backgeound checks.

Resolution: Corrected: 2022-11-24

The operation has two staff who were shadowing a staff person who did not have current background checks. There were also four employees who were working and had inactive backgeound checks.

Resolution: Corrected: 2022-11-24

The operation has two staff who were shadowing a staff person who did not have current background checks. There were also four employees who were working and had inactive backgeound checks.

Resolution: Corrected: 2022-11-24

Staff interfered with a child's attempt to make a complaint over the phone by not allowing privacy and refusing requests for privacy. Additionally, staff regularly listen to or monitor children's phone calls

Resolution: Corrected: 2022-12-29

Staff interfered with a child's attempt to make a complaint over the phone by not allowing privacy and refusing requests for privacy. Additionally, staff regularly listen to or monitor children's phone calls

Resolution: Corrected: 2022-12-29

Staff interfered with a child's attempt to make a complaint over the phone by not allowing privacy and refusing requests for privacy. Additionally, staff regularly listen to or monitor children's phone calls

Resolution: Corrected: 2022-12-29

A medication was observed stored in a small cup and not in the original container. The medication was not being administered at the time of observation. The medication was originally stored in a blister pack and was left in this cup due to the child refusing to take it in the morning.

Resolution: Corrected at inspection

A medication was observed stored in a small cup and not in the original container. The medication was not being administered at the time of observation. The medication was originally stored in a blister pack and was left in this cup due to the child refusing to take it in the morning.

Resolution: Corrected at inspection

A medication was observed stored in a small cup and not in the original container. The medication was not being administered at the time of observation. The medication was originally stored in a blister pack and was left in this cup due to the child refusing to take it in the morning.

Resolution: Corrected at inspection

Records that were requested during the course of this investigation were not given to RCCR timely. Some documents were requested but not made available to RCCR until another request 13 days later. Additionally records that were requested during an inspection were not provided during the inspection or 2 days later even after an additional request.

Resolution: Corrected: 2022-11-11

A child was not taken to receive medical care twice for severe abdominal pain. Their parent was called to take the child to receive medical care instead.

Resolution: Corrected: 2022-11-11

A child was not taken to receive medical care twice for severe abdominal pain. Their parent was called to take the child to receive medical care instead.

Resolution: Corrected: 2022-11-11

Records that were requested during the course of this investigation were not given to RCCR timely. Some documents were requested but not made available to RCCR until another request 13 days later. Additionally records that were requested during an inspection were not provided during the inspection or 2 days later even after an additional request.

Resolution: Corrected: 2022-11-11

A child was not taken to receive medical care twice for severe abdominal pain. Their parent was called to take the child to receive medical care instead.

Resolution: Corrected: 2022-11-11

Records that were requested during the course of this investigation were not given to RCCR timely. Some documents were requested but not made available to RCCR until another request 13 days later. Additionally records that were requested during an inspection were not provided during the inspection or 2 days later even after an additional request.

Resolution: Corrected: 2022-11-11

The EBI training certificates read that 50% of the training was focused on physical skills training and not 75% focused on techniques for less restrictive interventions

Resolution: Corrected: 2022-08-17

The operation could not produce EBI documentation from April or May 2022 and reported that they did not keep documentation for EBI that was performed prior to June 2022. Additionally the operation produced 11 EBI reports for June 2022, of which 9 did not include the specific technique of EBI performed, 8 did not include the length of time the EBI was performed for, and 10 did not document when the staff explained the behaviors necessary for the child to be released from a restraint.

Resolution: Corrected: 2022-08-17

The EBI training certificates read that 50% of the training was focused on physical skills training and not 75% focused on techniques for less restrictive interventions

Resolution: Corrected: 2022-08-17

The supervised experience log documents that the caregiver received 8 hours of "supervised training" on the same date as the training certificates show the caregiver is receiving training. There is no documentation that the caregiver received 40 hours of supervised experience with children in care.

Resolution: Corrected: 2022-08-17

On 11 of 11 EBI reports reviewed there was no post restraint discussion documented

Resolution: Corrected: 2022-08-17

The preservice is part of orientation.

Resolution: Corrected: 2022-08-17

A staff member's training records indicated that they received 37 hours of training in one day.

Resolution: Corrected: 2022-08-17

The operation could not produce EBI documentation from April or May 2022 and reported that they did not keep documentation for EBI that was performed prior to June 2022. Additionally the operation produced 11 EBI reports for June 2022, of which 9 did not include the specific technique of EBI performed, 8 did not include the length of time the EBI was performed for, and 10 did not document when the staff explained the behaviors necessary for the child to be released from a restraint.

Resolution: Corrected: 2022-08-17

The supervised experience log documents that the caregiver received 8 hours of "supervised training" on the same date as the training certificates show the caregiver is receiving training. There is no documentation that the caregiver received 40 hours of supervised experience with children in care.

Resolution: Corrected: 2022-08-17

On 11 of 11 EBI reports reviewed there was no post restraint discussion documented

Resolution: Corrected: 2022-08-17

The preservice is part of orientation.

Resolution: Corrected: 2022-08-17

A staff member's training records indicated that they received 37 hours of training in one day.

Resolution: Corrected: 2022-08-17

The EBI training certificates read that 50% of the training was focused on physical skills training and not 75% focused on techniques for less restrictive interventions

Resolution: Corrected: 2022-08-17

A staff member's training records indicated that they received 37 hours of training in one day.

Resolution: Corrected: 2022-08-17

The supervised experience log documents that the caregiver received 8 hours of "supervised training" on the same date as the training certificates show the caregiver is receiving training. There is no documentation that the caregiver received 40 hours of supervised experience with children in care.

Resolution: Corrected: 2022-08-17

The preservice is part of orientation.

Resolution: Corrected: 2022-08-17

The operation could not produce EBI documentation from April or May 2022 and reported that they did not keep documentation for EBI that was performed prior to June 2022. Additionally the operation produced 11 EBI reports for June 2022, of which 9 did not include the specific technique of EBI performed, 8 did not include the length of time the EBI was performed for, and 10 did not document when the staff explained the behaviors necessary for the child to be released from a restraint.

Resolution: Corrected: 2022-08-17

On 11 of 11 EBI reports reviewed there was no post restraint discussion documented

Resolution: Corrected: 2022-08-17

Three service plans did not have signatures of the child.

Resolution: Corrected: 2022-12-09

A staff member hit a child in the chest after the child had a verbal altercation with the staff member.

Resolution: Corrected: 2022-12-09

A staff member used physical discipline with a child in care instead of de-escalating, or other more appropriate methods to deal with a conflict.

Resolution: Corrected: 2022-12-09

Three service plans did not have signatures of the child.

Resolution: Corrected: 2022-12-09

Three service plans did not have signatures of the child.

Resolution: Corrected: 2022-12-09

A staff member hit a child in the chest after the child had a verbal altercation with the staff member.

Resolution: Corrected: 2022-12-09

A staff member used physical discipline with a child in care instead of de-escalating, or other more appropriate methods to deal with a conflict.

Resolution: Corrected: 2022-12-09

A staff member hit a child in the chest after the child had a verbal altercation with the staff member.

Resolution: Corrected: 2022-12-09

A staff member used physical discipline with a child in care instead of de-escalating, or other more appropriate methods to deal with a conflict.

Resolution: Corrected: 2022-12-09

The operation had one caregiver for 6 children who were receiving treatment services. During this time a serious incident occurred

Resolution: Corrected: 2022-09-21

The operation had one caregiver for 6 children who were receiving treatment services. During this time a serious incident occurred

Resolution: Corrected: 2022-09-21

The operation had one caregiver for 6 children who were receiving treatment services. During this time a serious incident occurred

Resolution: Corrected: 2022-09-21

Staff admitted to leaving children unsupervised on a couple of occasions when emergencies occurred.

Resolution: Corrected: 2022-08-16

Staff admitted to leaving children unsupervised on a couple of occasions when emergencies occurred.

Resolution: Corrected: 2022-08-16

Staff admitted to leaving children unsupervised on a couple of occasions when emergencies occurred.

Resolution: Corrected: 2022-08-16

Two staff performed a restraint on a child for a situation that was not considered an emergency.

Resolution: Corrected: 2022-08-24

Two staff performed a restraint on a child for a situation that was not considered an emergency.

Resolution: Corrected: 2022-08-24

Two staff implemented an improper hold by forcibly pushing and restraining a child against the wall.

Resolution: Corrected: 2022-08-24

The incident report which documented the restraint did not include he length of time the child was restrained.

Resolution: Corrected: 2022-08-24

No effort was made to provide privacy to a child that was restrained by two staff in front of 8 other children.

Resolution: Corrected: 2022-08-24

The incident report which documented the restraint did not include he length of time the child was restrained.

Resolution: Corrected: 2022-08-24

Two staff implemented an improper hold by forcibly pushing and restraining a child against the wall.

Resolution: Corrected: 2022-08-24

Two staff performed a restraint on a child for a situation that was not considered an emergency.

Resolution: Corrected: 2022-08-24

No effort was made to provide privacy to a child that was restrained by two staff in front of 8 other children.

Resolution: Corrected: 2022-08-24

The incident report which documented the restraint did not include he length of time the child was restrained.

Resolution: Corrected: 2022-08-24

Two staff implemented an improper hold by forcibly pushing and restraining a child against the wall.

Resolution: Corrected: 2022-08-24

No effort was made to provide privacy to a child that was restrained by two staff in front of 8 other children.

Resolution: Corrected: 2022-08-24

The incident reports which documented the restraint did not include the length of time the child was restrained.

Resolution: Corrected: 2022-08-17

The incident reports which documented the restraint did not include the length of time the child was restrained.

Resolution: Corrected: 2022-08-17

The incident reports which documented the restraint did not include the length of time the child was restrained.

Resolution: Corrected: 2022-08-17

A caregiver did not assist a staff member when two youths were involved in an altercation.

Resolution: Corrected: 2022-07-21

A caregiver did not assist a staff member when two youths were involved in an altercation.

Resolution: Corrected: 2022-07-21

A caregiver did not assist a staff member when two youths were involved in an altercation.

Resolution: Corrected: 2022-07-21

A staff member did not report a sexual assault of the two children in care. The operation was also informed that 3 staff members' actions may have neglected children in care. The operation did not report any of these incidents to statewide intake.

Resolution: Corrected: 2022-12-24

A caregiver was informed by 16-year-old and 14-year-old child in care that they were sexually assaulted and the caregiver observed blood on the children(s) clothing. The caregiver then failed to immediately seek medical attention or contact law enforcement as related to the incident.

Resolution: Corrected: 2022-12-24

Two children in care who had a history of sex trafficking and run-away behavior were allowed to go for a walk and eventually ran away.

Resolution: Corrected: 2022-12-24

After receiving two children into care, a staff member took two children to an unauthorized location. She had the children shower after a sexual assault before returning them to the operation. This staff member also allowed one of the children to leave with an unauthorized person.

Resolution: Corrected: 2022-12-24

Two children in care who had a history of sex trafficking and run-away behavior were allowed to go for a walk and eventually ran away.

Resolution: Corrected: 2022-12-24

After receiving two children into care, a staff member took two children to an unauthorized location. She had the children shower after a sexual assault before returning them to the operation. This staff member also allowed one of the children to leave with an unauthorized person.

Resolution: Corrected: 2022-12-24

A caregiver was informed by 16-year-old and 14-year-old child in care that they were sexually assaulted and the caregiver observed blood on the children(s) clothing. The caregiver then failed to immediately seek medical attention or contact law enforcement as related to the incident.

Resolution: Corrected: 2022-12-24

A staff member did not report a sexual assault of the two children in care. The operation was also informed that 3 staff members' actions may have neglected children in care. The operation did not report any of these incidents to statewide intake.

Resolution: Corrected: 2022-12-24

Two children in care who had a history of sex trafficking and run-away behavior were allowed to go for a walk and eventually ran away.

Resolution: Corrected: 2022-12-24

A staff member failed to seek medical attention for two children in care when they were observed with blood on their clothing and one child was complaining of pain and discomfort.

Resolution: Corrected: 2022-12-24

After receiving two children into care, a staff member took two children to an unauthorized location. She had the children shower after a sexual assault before returning them to the operation. This staff member also allowed one of the children to leave with an unauthorized person.

Resolution: Corrected: 2022-12-24

A staff member did not report a sexual assault of the two children in care. The operation was also informed that 3 staff members' actions may have neglected children in care. The operation did not report any of these incidents to statewide intake.

Resolution: Corrected: 2022-12-24

A staff member failed to seek medical attention for two children in care when they were observed with blood on their clothing and one child was complaining of pain and discomfort.

Resolution: Corrected: 2022-12-24

A staff member failed to seek medical attention for two children in care when they were observed with blood on their clothing and one child was complaining of pain and discomfort.

Resolution: Corrected: 2022-12-24

A caregiver was informed by 16-year-old and 14-year-old child in care that they were sexually assaulted and the caregiver observed blood on the children(s) clothing. The caregiver then failed to immediately seek medical attention or contact law enforcement as related to the incident.

Resolution: Corrected: 2022-12-24

A child in care did not receive therapy as per service plan. It later lead to the child in care engaging in self harming and destructive behavior.

Resolution: Corrected: 2022-08-26

A child in care did not receive therapy as per service plan. It later lead to the child in care engaging in self harming and destructive behavior.

Resolution: Corrected: 2022-08-26

The operation did not have a staff that was able to communicate by using ASL with a child in care that was hearing impaired. Communication devices were taken from a child in care as a form of discipline.

Resolution: Corrected: 2022-08-15

A preliminary service was not completed for a child in care.

Resolution: Corrected: 2022-08-15

A child in care did not receive therapy as per service plan. It later lead to the child in care engaging in self harming and destructive behavior.

Resolution: Corrected: 2022-08-26

The operation did not have a staff that was able to communicate by using ASL with a child in care that was hearing impaired. Communication devices were taken from a child in care as a form of discipline.

Resolution: Corrected: 2022-08-15

A preliminary service was not completed for a child in care.

Resolution: Corrected: 2022-08-15

A preliminary service was not completed for a child in care.

Resolution: Corrected: 2022-08-15

The operation did not have a staff that was able to communicate by using ASL with a child in care that was hearing impaired. Communication devices were taken from a child in care as a form of discipline.

Resolution: Corrected: 2022-08-15

A caregiver did not provide adequate supervision for children in care and was unaware of the ongoing activities that the youth were conducting.

Resolution: Corrected: 2022-07-21

A caregiver did not provide adequate supervision for children in care and was unaware of the ongoing activities that the youth were conducting.

Resolution: Corrected: 2022-07-21

A caregiver did not provide adequate supervision for children in care and was unaware of the ongoing activities that the youth were conducting.

Resolution: Corrected: 2022-07-21

A child in care was restrained longer than one minute.

Resolution: Corrected: 2022-07-20

A child in care was restrained longer than one minute.

Resolution: Corrected: 2022-07-20

A child in care was restrained longer than one minute.

Resolution: Corrected: 2022-07-20

Two of the CPR certificates reviewed did not have the trainer name, qualifications and the length of hours.

Resolution: Corrected: 2022-02-22

Two of the CPR certificates reviewed did not have the trainer name, qualifications and the length of hours.

Resolution: Corrected: 2022-02-22

Two of the CPR certificates reviewed did not have the trainer name, qualifications and the length of hours.

Resolution: Corrected: 2022-02-22

One out of two staff files reviewed did not have first aid training. The staff member received the training for first aid on 8/31/2021. The staff member is current.

Resolution: Corrected at inspection

One out of two staff files reviewed did not have first aid training. The staff member received the training for first aid on 8/31/2021. The staff member is current.

Resolution: Corrected at inspection

There were three rooms with graffiti on the walls.

Resolution: Corrected: 2021-09-10

There were three rooms with graffiti on the walls.

Resolution: Corrected: 2021-09-10

There were three rooms with graffiti on the walls.

Resolution: Corrected: 2021-09-10

One out of two staff files reviewed did not have first aid training. The staff member received the training for first aid on 8/31/2021. The staff member is current.

Resolution: Corrected at inspection

A child did not receive good care and treatment at a facility, when a caregiver was able to use the child's treatment needs to coerce him to engage in inappropriate relations.

Resolution: Corrected: 2022-01-29

A caregiver did not demonstrate self-control by having inappropriate sexual conversations, exchanging nude photos, and propositioning to engage in sexual activities with a child in care.

Resolution: Corrected: 2022-01-29

A caregiver was providing a child with tobacco products.

Resolution: Corrected: 2022-01-29

A caregiver did not demonstrate self-control by having inappropriate sexual conversations, exchanging nude photos, and propositioning to engage in sexual activities with a child in care.

Resolution: Corrected: 2022-01-29

A caregiver was providing a child with tobacco products.

Resolution: Corrected: 2022-01-29

A child did not receive good care and treatment at a facility, when a caregiver was able to use the child's treatment needs to coerce him to engage in inappropriate relations.

Resolution: Corrected: 2022-01-29

A caregiver was providing a child with tobacco products.

Resolution: Corrected: 2022-01-29

A caregiver did not demonstrate self-control by having inappropriate sexual conversations, exchanging nude photos, and propositioning to engage in sexual activities with a child in care.

Resolution: Corrected: 2022-01-29

A child did not receive good care and treatment at a facility, when a caregiver was able to use the child's treatment needs to coerce him to engage in inappropriate relations.

Resolution: Corrected: 2022-01-29

Two caregivers were not informed about all of a child's food allergies.

Resolution: Corrected: 2021-10-07

Two caregivers were not informed about all of a child's food allergies.

Resolution: Corrected: 2021-10-07

Menus do not document substitutions.

Resolution: Corrected: 2021-10-07

Menus do not document substitutions.

Resolution: Corrected: 2021-10-07

Two caregivers were not informed about all of a child's food allergies.

Resolution: Corrected: 2021-10-07

Menus do not document substitutions.

Resolution: Corrected: 2021-10-07

A refridgerator near the serving area in the cafeteria was found to be unplugged and contained a package of spoiled, molded food.

Resolution: Corrected at inspection

A refridgerator near the serving area in the cafeteria was found to be unplugged and contained a package of spoiled, molded food.

Resolution: Corrected at inspection

A refridgerator near the serving area in the cafeteria was found to be unplugged and contained a package of spoiled, molded food.

Resolution: Corrected at inspection

A child with previous aggressive behavior was able to engage in a second altercation with another child in care.

Resolution: Corrected: 2022-08-31

A child with previous aggressive behavior was able to engage in a second altercation with another child in care.

Resolution: Corrected: 2022-08-31

A child with previous aggressive behavior was able to engage in a second altercation with another child in care.

Resolution: Corrected: 2022-08-31

All children placed at the operation are restricted from making phone calls for the first seven days without considering the best interest of each child.

Resolution: Corrected: 2021-08-27

All children in care are not allowed to shave.

Resolution: Corrected: 2021-08-27

The operation has provided staff with an employee handbook that contradicts their written operational policies, and staff are not consistently following either set of procedures.

Resolution: Corrected: 2021-08-27

The operation is performing routine searches for residents that require the removal of all clothing.

Resolution: Corrected: 2021-08-24

All children placed at the operation are restricted from making phone calls for the first seven days without considering the best interest of each child.

Resolution: Corrected: 2021-08-27

The operation has provided staff with an employee handbook that contradicts their written operational policies, and staff are not consistently following either set of procedures.

Resolution: Corrected: 2021-08-27

All children in care are not allowed to shave.

Resolution: Corrected: 2021-08-27

The operation is performing routine searches for residents that require the removal of all clothing.

Resolution: Corrected: 2021-08-24

The operation is performing routine searches for residents that require the removal of all clothing.

Resolution: Corrected: 2021-08-24

All children in care are not allowed to shave.

Resolution: Corrected: 2021-08-27

The operation has provided staff with an employee handbook that contradicts their written operational policies, and staff are not consistently following either set of procedures.

Resolution: Corrected: 2021-08-27

All children placed at the operation are restricted from making phone calls for the first seven days without considering the best interest of each child.

Resolution: Corrected: 2021-08-27

A child overdosed on over-the-counter medication and did not receive proper medical attention.

Resolution: Corrected: 2021-08-31

A staff failed to provide appropriate supervision and monitor vitals for a 16 year old youth and a 17 year old youth after they ingested several non-prescribed over the counter medications.

Resolution: Corrected: 2021-08-31

The administrator failed to ensure that children in care received appropriate and timely medical care, that staff conducted assigned duties, and ensured the environment was safe for children in care. The operation has had multiple concerns for supervision that have not been addressed in a manner that improves the operation compliance.

Resolution: Corrected: 2021-08-31

A staff failed to provide appropriate supervision and monitor vitals for a 16 year old youth and a 17 year old youth after they ingested several non-prescribed over the counter medications.

Resolution: Corrected: 2021-08-31

Two youths ran away from the operation. There parents were not notified within 6 hours of the youths leaving the operation.

Resolution: Corrected: 2021-08-31

A child overdosed on over-the-counter medication and did not receive proper medical attention.

Resolution: Corrected: 2021-08-31

The caregiver informed about the activities the youth were involved in previously did not provide the level of supervision required to ensure children's safety.

Resolution: Corrected: 2021-08-31

A child overdosed on over-the-counter medication and did not receive proper medical attention.

Resolution: Corrected: 2021-08-31

The caregiver informed about the activities the youth were involved in previously did not provide the level of supervision required to ensure children's safety.

Resolution: Corrected: 2021-08-31

A staff failed to provide appropriate supervision and monitor vitals for a 16 year old youth and a 17 year old youth after they ingested several non-prescribed over the counter medications.

Resolution: Corrected: 2021-08-31

The administrator failed to ensure that children in care received appropriate and timely medical care, that staff conducted assigned duties, and ensured the environment was safe for children in care. The operation has had multiple concerns for supervision that have not been addressed in a manner that improves the operation compliance.

Resolution: Corrected: 2021-08-31

The administrator failed to ensure that children in care received appropriate and timely medical care, that staff conducted assigned duties, and ensured the environment was safe for children in care. The operation has had multiple concerns for supervision that have not been addressed in a manner that improves the operation compliance.

Resolution: Corrected: 2021-08-31

Two youths ran away from the operation. There parents were not notified within 6 hours of the youths leaving the operation.

Resolution: Corrected: 2021-08-31

Two youths ran away from the operation. There parents were not notified within 6 hours of the youths leaving the operation.

Resolution: Corrected: 2021-08-31

The caregiver informed about the activities the youth were involved in previously did not provide the level of supervision required to ensure children's safety.

Resolution: Corrected: 2021-08-31

There were multiple restrooms in the boys and girls area that had splattered paint on the walls and the floors. In addition, the restrooms were dirty and had areas that were not clean.

Resolution: Corrected: 2021-06-09

There were several areas of the facility that either had giraffe, holes in the walls and was not clean.

Resolution: Corrected: 2021-07-16

There were multiple restrooms in the boys and girls area that had splattered paint on the walls and the floors. In addition, the restrooms were dirty and had areas that were not clean.

Resolution: Corrected: 2021-06-09

There were multiple restrooms in the boys and girls area that had splattered paint on the walls and the floors. In addition, the restrooms were dirty and had areas that were not clean.

Resolution: Corrected: 2021-06-09

There were several areas of the facility that either had giraffe, holes in the walls and was not clean.

Resolution: Corrected: 2021-07-16

There were several areas of the facility that either had giraffe, holes in the walls and was not clean.

Resolution: Corrected: 2021-07-16

The assigned caregiver did not provide the level of supervision required to ensure child's safety.

Resolution: Corrected: 2021-10-13

The caregiver did not use good judgment when they did not follow the operations procedures in not allowing children of the opposite sex to be together. This resulted in two children acting inappropriately together.

Resolution: Corrected: 2021-10-13

The assigned caregiver did not provide the level of supervision required to ensure child's safety.

Resolution: Corrected: 2021-10-13

The caregiver did not use good judgment when they did not follow the operations procedures in not allowing children of the opposite sex to be together. This resulted in two children acting inappropriately together.

Resolution: Corrected: 2021-10-13

The assigned caregiver did not provide the level of supervision required to ensure child's safety.

Resolution: Corrected: 2021-10-13

The caregiver did not use good judgment when they did not follow the operations procedures in not allowing children of the opposite sex to be together. This resulted in two children acting inappropriately together.

Resolution: Corrected: 2021-10-13

A physician completed exams with youths without having another staff member observing.

Resolution: Corrected: 2021-10-13

A physician completed exams with youths without having another staff member observing.

Resolution: Corrected: 2021-10-13

A physician completed exams with youths without having another staff member observing.

Resolution: Corrected: 2021-10-13

A staff member was falsifying documentation concerning visual room checks at night.

Resolution: Corrected: 2022-09-08

The night time visual checks on the children were not being conducted properly by checking on each child in the room.

Resolution: Corrected: 2022-09-08

A staff member was falsifying documentation concerning visual room checks at night.

Resolution: Corrected: 2022-09-08

The youth were cheeking their medication and not taking it as prescribed when the staff would administer the medication.

Resolution: Corrected: 2022-09-08

The night time visual checks on the children were not being conducted properly by checking on each child in the room.

Resolution: Corrected: 2022-09-08

The night time visual checks on the children were not being conducted properly by checking on each child in the room.

Resolution: Corrected: 2022-09-08

A staff member was falsifying documentation concerning visual room checks at night.

Resolution: Corrected: 2022-09-08

The youth were cheeking their medication and not taking it as prescribed when the staff would administer the medication.

Resolution: Corrected: 2022-09-08

A group of children engaged in sexually activity and used unauthorized medication, due to a caregiver not providing the appropriate level of supervision.

Resolution: Corrected: 2022-09-08

A group of children engaged in sexually activity and used unauthorized medication, due to a caregiver not providing the appropriate level of supervision.

Resolution: Corrected: 2022-09-08

The youth were cheeking their medication and not taking it as prescribed when the staff would administer the medication.

Resolution: Corrected: 2022-09-08

A group of children engaged in sexually activity and used unauthorized medication, due to a caregiver not providing the appropriate level of supervision.

Resolution: Corrected: 2022-09-08

Facility keys were left accessible to children in care. A child used those keys to obtain a razor and then self -harmed.

Resolution: Corrected: 2022-02-28

A 14 year old, with a history of self harm, was left on the unit without a caregiver. This resulted in the child gaining access to a dangerous object and engaging in self harm. The injuries sustained required medical attention.

Resolution: Corrected: 2022-02-28

Fort Behavioral Health reports that there is no set criteria for monitoring children. Staff are not being designated to complete individualized supervision based on risks identified.

Resolution: Corrected: 2022-05-31

Facility keys were left accessible to children in care. A child used those keys to obtain a razor and then self -harmed.

Resolution: Corrected: 2022-02-28

A staff member documented that and observation of a child was completed, when it was not done.

Resolution: Corrected: 2022-05-31

The Columbia-Suicide Severity Rating Scale measured a child as high risk at admissions. The child and collateral reports disclosed a history of self harm by cutting. The initial service plan does not set a criteria for supervision neither does it implement a safety plan.

Resolution: Corrected: 2022-02-28

A 14 year old, with a history of self harm, was left on the unit without a caregiver. This resulted in the child gaining access to a dangerous object and engaging in self harm. The injuries sustained required medical attention.

Resolution: Corrected: 2022-02-28

Fort Behavioral Health reports that there is no set criteria for monitoring children. Staff are not being designated to complete individualized supervision based on risks identified.

Resolution: Corrected: 2022-05-31

The Columbia-Suicide Severity Rating Scale measured a child as high risk at admissions. The child and collateral reports disclosed a history of self harm by cutting. The initial service plan does not set a criteria for supervision neither does it implement a safety plan.

Resolution: Corrected: 2022-02-28

Facility keys were left accessible to children in care. A child used those keys to obtain a razor and then self -harmed.

Resolution: Corrected: 2022-02-28

A staff member documented that and observation of a child was completed, when it was not done.

Resolution: Corrected: 2022-05-31

A 14 year old, with a history of self harm, was left on the unit without a caregiver. This resulted in the child gaining access to a dangerous object and engaging in self harm. The injuries sustained required medical attention.

Resolution: Corrected: 2022-02-28

Fort Behavioral Health reports that there is no set criteria for monitoring children. Staff are not being designated to complete individualized supervision based on risks identified.

Resolution: Corrected: 2022-05-31

The Columbia-Suicide Severity Rating Scale measured a child as high risk at admissions. The child and collateral reports disclosed a history of self harm by cutting. The initial service plan does not set a criteria for supervision neither does it implement a safety plan.

Resolution: Corrected: 2022-02-28

A staff member documented that and observation of a child was completed, when it was not done.

Resolution: Corrected: 2022-05-31

An employee was working before the initial background check was submitted.

Resolution: Corrected: 2021-05-25

Children in care were allowed to have physical inappropriate contact with each other multiple times while being supervised.

Resolution: Corrected: 2021-05-28

An employee was working before the initial background check was submitted.

Resolution: Corrected: 2021-05-25

Children in care were allowed to have physical inappropriate contact with each other multiple times while being supervised.

Resolution: Corrected: 2021-05-28

Two children engaged in inappropriate physical contact. The Abuse Hotline was not notified.

Resolution: Corrected: 2021-05-28

Two children engaged in inappropriate physical contact. The Abuse Hotline was not notified.

Resolution: Corrected: 2021-05-28

Children in care were allowed to have physical inappropriate contact with each other multiple times while being supervised.

Resolution: Corrected: 2021-05-28

Two children engaged in inappropriate physical contact. The Abuse Hotline was not notified.

Resolution: Corrected: 2021-05-28

An employee was working before the initial background check was submitted.

Resolution: Corrected: 2021-05-25