Armanis House Inc. Residential Care

Staff records were reviewed and the tuberculosis screening results were not located in the file.

Resolution: Corrected: 2025-06-10

The operations peoples list for background checks was validated last on 2/26/25.

Resolution: Corrected: 2025-06-10

Serious incident reports were reviewed which did not indicate the roles of the staff involved in the incidents.

Resolution: Corrected: 2025-06-10

Staff files were missing the required reference checks and or the date that the reference check was completed and the outcome of the reference check.

Resolution: Corrected: 2025-06-10

Staff files were missing the required reference checks and or the date that the reference check was completed and the outcome of the reference check.

Resolution: Corrected: 2025-06-10

Staff records were reviewed and the tuberculosis screening results were not located in the file.

Resolution: Corrected: 2025-06-10

The operations peoples list for background checks was validated last on 2/26/25.

Resolution: Corrected: 2025-06-10

Serious incident reports were reviewed which did not indicate the roles of the staff involved in the incidents.

Resolution: Corrected: 2025-06-10

Staff files were missing the required reference checks and or the date that the reference check was completed and the outcome of the reference check.

Resolution: Corrected: 2025-06-10

Staff records were reviewed and the tuberculosis screening results were not located in the file.

Resolution: Corrected: 2025-06-10

The operations peoples list for background checks was validated last on 2/26/25.

Resolution: Corrected: 2025-06-10

Staff records were reviewed and the tuberculosis screening results were not located in the file.

Resolution: Corrected: 2025-06-10

Serious incident reports were reviewed which did not indicate the roles of the staff involved in the incidents.

Resolution: Corrected: 2025-06-10

Serious incident reports were reviewed which did not indicate the roles of the staff involved in the incidents.

Resolution: Corrected: 2025-06-10

The operations peoples list for background checks was validated last on 2/26/25.

Resolution: Corrected: 2025-06-10

Staff records were reviewed and the tuberculosis screening results were not located in the file.

Resolution: Corrected: 2025-06-10

Staff files were missing the required reference checks and or the date that the reference check was completed and the outcome of the reference check.

Resolution: Corrected: 2025-06-10

The operations peoples list for background checks was validated last on 2/26/25.

Resolution: Corrected: 2025-06-10

Serious incident reports were reviewed which did not indicate the roles of the staff involved in the incidents.

Resolution: Corrected: 2025-06-10

Staff files were missing the required reference checks and or the date that the reference check was completed and the outcome of the reference check.

Resolution: Corrected: 2025-06-10

The thermometers in the freezer and refrigerator are not functioning properly to give an accurate temperature reading.

Resolution: Corrected: 2025-02-24

The thermometers in the freezer and refrigerator are not functioning properly to give an accurate temperature reading.

Resolution: Corrected: 2025-02-24

The thermometers in the freezer and refrigerator are not functioning properly to give an accurate temperature reading.

Resolution: Corrected: 2025-02-24

The thermometers in the freezer and refrigerator are not functioning properly to give an accurate temperature reading.

Resolution: Corrected: 2025-02-24

The thermometers in the freezer and refrigerator are not functioning properly to give an accurate temperature reading.

Resolution: Corrected: 2025-02-24

Based on the documents/credentials provided for verification, the treatment director doesn't meet the requirements for emotional disorders.

Resolution: Corrected: 2024-09-21

Based on the documents/credentials provided for verification, the treatment director doesn't meet the requirements for emotional disorders.

Resolution: Corrected: 2024-09-21

Based on the documents/credentials provided for verification, the treatment director doesn't meet the requirements for emotional disorders.

Resolution: Corrected: 2024-09-21

Based on the documents/credentials provided for verification, the treatment director doesn't meet the requirements for emotional disorders.

Resolution: Corrected: 2024-09-21

Residents left the facility and went out with an unknown male without the knowledge of staff on duty. Residents left the facility through the Neighbours fence, and they stated during interview that staff did not see them leave the facility.

Resolution: Corrected: 2024-09-09

3 children service plan reviewed did not have the date the service plan was developed.

Resolution: Corrected: 2024-09-09

3 children service plan reviewed did not have signatures of service planning team members.

Resolution: Corrected: 2024-09-09

According to the information in a child initial service plan, the child was admitted on 1-5-24 and the date initial service plan was completed on 8-2-24 which is about 210 days after placement.

Resolution: Corrected: 2024-09-09

One child's date of admission is missing in the Unauthorized absence log

Resolution: Corrected: 2024-09-09

3 children service plan reviewed did not have the names and roles of the service plan participants.

Resolution: Corrected: 2024-09-09

3 children service plan reviewed did not have signatures of service planning team members.

Resolution: Corrected: 2024-09-09

3 children service plan reviewed did not have the names and roles of the service plan participants.

Resolution: Corrected: 2024-09-09

3 children service plan reviewed did not have the date the service plan was developed.

Resolution: Corrected: 2024-09-09

According to the information in a child initial service plan, the child was admitted on 1-5-24 and the date initial service plan was completed on 8-2-24 which is about 210 days after placement.

Resolution: Corrected: 2024-09-09

One child's date of admission is missing in the Unauthorized absence log

Resolution: Corrected: 2024-09-09

3 children service plan reviewed did not have the names and roles of the service plan participants.

Resolution: Corrected: 2024-09-09

Residents left the facility and went out with an unknown male without the knowledge of staff on duty. Residents left the facility through the Neighbours fence, and they stated during interview that staff did not see them leave the facility.

Resolution: Corrected: 2024-09-09

3 children service plan reviewed did not have signatures of service planning team members.

Resolution: Corrected: 2024-09-09

According to the information in a child initial service plan, the child was admitted on 1-5-24 and the date initial service plan was completed on 8-2-24 which is about 210 days after placement.

Resolution: Corrected: 2024-09-09

3 children service plan reviewed did not have the date the service plan was developed.

Resolution: Corrected: 2024-09-09

One child's date of admission is missing in the Unauthorized absence log

Resolution: Corrected: 2024-09-09

3 children service plan reviewed did not have signatures of service planning team members.

Resolution: Corrected: 2024-09-09

3 children service plan reviewed did not have the date the service plan was developed.

Resolution: Corrected: 2024-09-09

3 children service plan reviewed did not have the names and roles of the service plan participants.

Resolution: Corrected: 2024-09-09

Residents left the facility and went out with an unknown male without the knowledge of staff on duty. Residents left the facility through the Neighbours fence, and they stated during interview that staff did not see them leave the facility.

Resolution: Corrected: 2024-09-09

According to the information in a child initial service plan, the child was admitted on 1-5-24 and the date initial service plan was completed on 8-2-24 which is about 210 days after placement.

Resolution: Corrected: 2024-09-09

Residents left the facility and went out with an unknown male without the knowledge of staff on duty. Residents left the facility through the Neighbours fence, and they stated during interview that staff did not see them leave the facility.

Resolution: Corrected: 2024-09-09

One child's date of admission is missing in the Unauthorized absence log

Resolution: Corrected: 2024-09-09

3 children service plan reviewed did not have the names and roles of the service plan participants.

Resolution: Corrected: 2024-09-09

Residents left the facility and went out with an unknown male without the knowledge of staff on duty. Residents left the facility through the Neighbours fence, and they stated during interview that staff did not see them leave the facility.

Resolution: Corrected: 2024-09-09

3 children service plan reviewed did not have signatures of service planning team members.

Resolution: Corrected: 2024-09-09

According to the information in a child initial service plan, the child was admitted on 1-5-24 and the date initial service plan was completed on 8-2-24 which is about 210 days after placement.

Resolution: Corrected: 2024-09-09

3 children service plan reviewed did not have the date the service plan was developed.

Resolution: Corrected: 2024-09-09

One child's date of admission is missing in the Unauthorized absence log

Resolution: Corrected: 2024-09-09

Operation staff present at the operation does not a drug screen in employee file.

Resolution: Corrected: 2024-06-13

Operation staff files do not include correct drug screens to show the required screening areas and did not include how operation confirmed false positives below 2% and false negatives below 8% on all drugs screened.

Resolution: Corrected: 2024-06-13

Operation staff files do not include correct drug screens to show the required screening areas and did not include how operation confirmed false positives below 2% and false negatives below 8% on all drugs screened.

Resolution: Corrected: 2024-06-13

Operation staff files do not include correct drug screens to show the required screening areas and did not include how operation confirmed false positives below 2% and false negatives below 8% on all drugs screened.

Resolution: Corrected: 2024-06-13

Operation staff present at the operation does not a drug screen in employee file.

Resolution: Corrected: 2024-06-13

Operation staff present at the operation does not a drug screen in employee file.

Resolution: Corrected: 2024-06-13

Operation staff files do not include correct drug screens to show the required screening areas and did not include how operation confirmed false positives below 2% and false negatives below 8% on all drugs screened.

Resolution: Corrected: 2024-06-13

Operation staff present at the operation does not a drug screen in employee file.

Resolution: Corrected: 2024-06-13

Operation staff files do not include correct drug screens to show the required screening areas and did not include how operation confirmed false positives below 2% and false negatives below 8% on all drugs screened.

Resolution: Corrected: 2024-06-13

Operation staff present at the operation does not a drug screen in employee file.

Resolution: Corrected: 2024-06-13

During the inspection, it was observed that multiple items in the freezer were not properly labeled with expiration dates after being removed from its original packaging.

Resolution: Corrected: 2024-05-20

During the inspection, in the bathroom down the hallway near the living room on the left side, the left knob on the first bathroom sink turns, but does not produce any water.

Resolution: Corrected: 2024-05-20

Child File had a medication log that was not completely filled out and did not list the reason why medication was given.

Resolution: Corrected: 2024-05-08

Staff present at the operation did not have a current job description to indicate their role as well as official date of hire for type of position.

Resolution: Corrected: 2024-05-13

Operation staff files do not include correct drug screens to show the required screening areas and did not include how operation confirmed false positives below 2% and false negatives below 8% on all drugs screened.

Resolution: Corrected: 2024-05-10

Operation staff/volunteer present at the operation with access to children in care did not have a completed TB screening. Another staff file did not have a TB test completed within 30 days before or after hire date.

Resolution: Corrected: 2024-05-08

Operation used a form for serious incident reporting that did not include required information per minimum standards.

Resolution: Corrected: 2024-05-13

Operation staff files reviewed did not have completed references for staff and volunteers present at the operation.

Resolution: Corrected: 2024-05-10

Operation staff present at the operation does not have notarized affidavit but was signed by employee in May, 2024.

Resolution: Corrected: 2024-05-08

Operation staff informed licensing they did not have debriefing documentation for children who eloped from care.

Resolution: Corrected: 2024-05-13

Operation staff files reviewed did not show employment history for the last five years and did not indicate if staff did not have employment history prior to working at the operation.

Resolution: Corrected: 2024-05-10

Operation staff present at the operation does not a drug screen in employee file.

Resolution: Corrected: 2024-05-10

During the inspection, it was observed that multiple items in the freezer were not properly labeled with expiration dates after being removed from its original packaging.

Resolution: Corrected: 2024-05-20

During the inspection, in the bathroom down the hallway near the living room on the left side, the left knob on the first bathroom sink turns, but does not produce any water.

Resolution: Corrected: 2024-05-20

During the inspection, in the bathroom down the hallway near the living room on the left side, the left knob on the first bathroom sink turns, but does not produce any water.

Resolution: Corrected: 2024-05-20

During the inspection, it was observed that multiple items in the freezer were not properly labeled with expiration dates after being removed from its original packaging.

Resolution: Corrected: 2024-05-20

During the inspection, it was observed that multiple items in the freezer were not properly labeled with expiration dates after being removed from its original packaging.

Resolution: Corrected: 2024-05-20

During the inspection, in the bathroom down the hallway near the living room on the left side, the left knob on the first bathroom sink turns, but does not produce any water.

Resolution: Corrected: 2024-05-20

During the inspection, it was observed that multiple items in the freezer were not properly labeled with expiration dates after being removed from its original packaging.

Resolution: Corrected: 2024-05-20

During the inspection, in the bathroom down the hallway near the living room on the left side, the left knob on the first bathroom sink turns, but does not produce any water.

Resolution: Corrected: 2024-05-20

Operation used a form for serious incident reporting that did not include required information per minimum standards.

Resolution: Corrected: 2024-05-13

Operation staff files reviewed did not show employment history for the last five years and did not indicate if staff did not have employment history prior to working at the operation.

Resolution: Corrected: 2024-05-10

Operation staff files do not include correct drug screens to show the required screening areas and did not include how operation confirmed false positives below 2% and false negatives below 8% on all drugs screened.

Resolution: Corrected: 2024-05-10

Child File had a medication log that was not completely filled out and did not list the reason why medication was given.

Resolution: Corrected: 2024-05-08

Staff present at the operation did not have a current job description to indicate their role as well as official date of hire for type of position.

Resolution: Corrected: 2024-05-13

Operation staff/volunteer present at the operation with access to children in care did not have a completed TB screening. Another staff file did not have a TB test completed within 30 days before or after hire date.

Resolution: Corrected: 2024-05-08

Operation staff informed licensing they did not have debriefing documentation for children who eloped from care.

Resolution: Corrected: 2024-05-13

Operation staff present at the operation does not a drug screen in employee file.

Resolution: Corrected: 2024-05-10

Operation staff files reviewed did not have completed references for staff and volunteers present at the operation.

Resolution: Corrected: 2024-05-10

Operation staff present at the operation does not have notarized affidavit but was signed by employee in May, 2024.

Resolution: Corrected: 2024-05-08

Operation staff present at the operation does not a drug screen in employee file.

Resolution: Corrected: 2024-05-10

Operation staff present at the operation does not have notarized affidavit but was signed by employee in May, 2024.

Resolution: Corrected: 2024-05-08

Child File had a medication log that was not completely filled out and did not list the reason why medication was given.

Resolution: Corrected: 2024-05-08

Operation staff files reviewed did not show employment history for the last five years and did not indicate if staff did not have employment history prior to working at the operation.

Resolution: Corrected: 2024-05-10

Operation staff files reviewed did not have completed references for staff and volunteers present at the operation.

Resolution: Corrected: 2024-05-10

Operation staff informed licensing they did not have debriefing documentation for children who eloped from care.

Resolution: Corrected: 2024-05-13

Staff present at the operation did not have a current job description to indicate their role as well as official date of hire for type of position.

Resolution: Corrected: 2024-05-13

Operation staff/volunteer present at the operation with access to children in care did not have a completed TB screening. Another staff file did not have a TB test completed within 30 days before or after hire date.

Resolution: Corrected: 2024-05-08

Operation used a form for serious incident reporting that did not include required information per minimum standards.

Resolution: Corrected: 2024-05-13

Operation staff files do not include correct drug screens to show the required screening areas and did not include how operation confirmed false positives below 2% and false negatives below 8% on all drugs screened.

Resolution: Corrected: 2024-05-10

Operation staff/volunteer present at the operation with access to children in care did not have a completed TB screening. Another staff file did not have a TB test completed within 30 days before or after hire date.

Resolution: Corrected: 2024-05-08

Operation staff files reviewed did not have completed references for staff and volunteers present at the operation.

Resolution: Corrected: 2024-05-10

Child File had a medication log that was not completely filled out and did not list the reason why medication was given.

Resolution: Corrected: 2024-05-08

Operation staff files do not include correct drug screens to show the required screening areas and did not include how operation confirmed false positives below 2% and false negatives below 8% on all drugs screened.

Resolution: Corrected: 2024-05-10

Operation staff present at the operation does not have notarized affidavit but was signed by employee in May, 2024.

Resolution: Corrected: 2024-05-08

Operation staff files reviewed did not show employment history for the last five years and did not indicate if staff did not have employment history prior to working at the operation.

Resolution: Corrected: 2024-05-10

Staff present at the operation did not have a current job description to indicate their role as well as official date of hire for type of position.

Resolution: Corrected: 2024-05-13

Operation staff present at the operation does not have notarized affidavit but was signed by employee in May, 2024.

Resolution: Corrected: 2024-05-08

Operation staff informed licensing they did not have debriefing documentation for children who eloped from care.

Resolution: Corrected: 2024-05-13

Operation staff present at the operation does not a drug screen in employee file.

Resolution: Corrected: 2024-05-10

Operation used a form for serious incident reporting that did not include required information per minimum standards.

Resolution: Corrected: 2024-05-13

Operation staff/volunteer present at the operation with access to children in care did not have a completed TB screening. Another staff file did not have a TB test completed within 30 days before or after hire date.

Resolution: Corrected: 2024-05-08

Operation staff files reviewed did not have completed references for staff and volunteers present at the operation.

Resolution: Corrected: 2024-05-10

Child File had a medication log that was not completely filled out and did not list the reason why medication was given.

Resolution: Corrected: 2024-05-08

Operation staff files do not include correct drug screens to show the required screening areas and did not include how operation confirmed false positives below 2% and false negatives below 8% on all drugs screened.

Resolution: Corrected: 2024-05-10

Operation used a form for serious incident reporting that did not include required information per minimum standards.

Resolution: Corrected: 2024-05-13

Operation staff present at the operation does not a drug screen in employee file.

Resolution: Corrected: 2024-05-10

Operation staff informed licensing they did not have debriefing documentation for children who eloped from care.

Resolution: Corrected: 2024-05-13

Staff present at the operation did not have a current job description to indicate their role as well as official date of hire for type of position.

Resolution: Corrected: 2024-05-13

Operation staff files reviewed did not show employment history for the last five years and did not indicate if staff did not have employment history prior to working at the operation.

Resolution: Corrected: 2024-05-10

A child file did not have a documentation of notice being provided to their guardian of service plan meeting.

Resolution: Corrected: 2024-03-28

One employee file did not have a CPR/First Aid certification.

Resolution: Corrected: 2024-03-28

Operation used a form for serious incident reporting that did not include required information per minimum standards.

Resolution: Corrected: 2024-03-28

One employee file did not have transportation training.

Resolution: Corrected: 2024-03-28

One employee file had expired normalcy training.

Resolution: Corrected: 2024-03-28

A child file had identified high risk behaviors, however there was no documented safety plan that would be implemented on how to address the behaviors.

Resolution: Corrected: 2024-03-28

One employee file had psychotropic medication training that expired in January 2024.

Resolution: Corrected: 2024-03-28

A child file did not have a preliminary service plan completed within the required time frame.

Resolution: Corrected: 2024-03-28

Operation used a form for serious incident reporting that did not include required information per minimum standards.

Resolution: Corrected: 2024-03-28

One employee file had psychotropic medication training that expired in January 2024.

Resolution: Corrected: 2024-03-28

One employee file did not have a CPR/First Aid certification.

Resolution: Corrected: 2024-03-28

One employee file had expired normalcy training.

Resolution: Corrected: 2024-03-28

A child file did not have a documentation of notice being provided to their guardian of service plan meeting.

Resolution: Corrected: 2024-03-28

One employee file did not have transportation training.

Resolution: Corrected: 2024-03-28

A child file did not have a preliminary service plan completed within the required time frame.

Resolution: Corrected: 2024-03-28

Operation used a form for serious incident reporting that did not include required information per minimum standards.

Resolution: Corrected: 2024-03-28

One employee file had expired normalcy training.

Resolution: Corrected: 2024-03-28

A child file did not have a preliminary service plan completed within the required time frame.

Resolution: Corrected: 2024-03-28

A child file had identified high risk behaviors, however there was no documented safety plan that would be implemented on how to address the behaviors.

Resolution: Corrected: 2024-03-28

A child file did not have a documentation of notice being provided to their guardian of service plan meeting.

Resolution: Corrected: 2024-03-28

One employee file had psychotropic medication training that expired in January 2024.

Resolution: Corrected: 2024-03-28

One employee file did not have transportation training.

Resolution: Corrected: 2024-03-28

One employee file did not have a CPR/First Aid certification.

Resolution: Corrected: 2024-03-28

A child file had identified high risk behaviors, however there was no documented safety plan that would be implemented on how to address the behaviors.

Resolution: Corrected: 2024-03-28

One employee file did not have transportation training.

Resolution: Corrected: 2024-03-28

A child file did not have a preliminary service plan completed within the required time frame.

Resolution: Corrected: 2024-03-28

A child file did not have a documentation of notice being provided to their guardian of service plan meeting.

Resolution: Corrected: 2024-03-28

One employee file had expired normalcy training.

Resolution: Corrected: 2024-03-28

One employee file had psychotropic medication training that expired in January 2024.

Resolution: Corrected: 2024-03-28

Operation used a form for serious incident reporting that did not include required information per minimum standards.

Resolution: Corrected: 2024-03-28

A child file had identified high risk behaviors, however there was no documented safety plan that would be implemented on how to address the behaviors.

Resolution: Corrected: 2024-03-28

One employee file did not have a CPR/First Aid certification.

Resolution: Corrected: 2024-03-28

One employee file did not have transportation training.

Resolution: Corrected: 2024-03-28

A child file did not have a preliminary service plan completed within the required time frame.

Resolution: Corrected: 2024-03-28

A child file did not have a documentation of notice being provided to their guardian of service plan meeting.

Resolution: Corrected: 2024-03-28

A child file had identified high risk behaviors, however there was no documented safety plan that would be implemented on how to address the behaviors.

Resolution: Corrected: 2024-03-28

One employee file did not have a CPR/First Aid certification.

Resolution: Corrected: 2024-03-28

One employee file had expired normalcy training.

Resolution: Corrected: 2024-03-28

One employee file had psychotropic medication training that expired in January 2024.

Resolution: Corrected: 2024-03-28

Operation used a form for serious incident reporting that did not include required information per minimum standards.

Resolution: Corrected: 2024-03-28

A service plan that identified a child as having high risk behaviors for AWOL, self-harm, and harm to others stated she did not require supervision outside the home and included no supervision requirements for the child while outside the home.

Resolution: Corrected: 2024-04-17

A person identified by the Administrator as a peer-to-peer support/volunteer was present at the operation on 2/11/24 and one other time prior, without a background check. Another citation related to this deficiency within the next 6 months may result in an additional penalty and other enforcement actions.

Resolution: Corrected: 2024-04-11

A person identified by the Administrator as a peer-to-peer support/volunteer was present at the operation on 2/11/24 and one other time prior, without a background check. Another citation related to this deficiency within the next 6 months may result in an additional penalty and other enforcement actions.

Resolution: Corrected: 2024-04-11

A service plan that identified a child as having high risk behaviors for AWOL, self-harm, and harm to others stated she did not require supervision outside the home and included no supervision requirements for the child while outside the home.

Resolution: Corrected: 2024-04-17

A person identified by the Administrator as a peer-to-peer support/volunteer was present at the operation on 2/11/24 and one other time prior, without a background check. Another citation related to this deficiency within the next 6 months may result in an additional penalty and other enforcement actions.

Resolution: Corrected: 2024-04-11

A service plan that identified a child as having high risk behaviors for AWOL, self-harm, and harm to others stated she did not require supervision outside the home and included no supervision requirements for the child while outside the home.

Resolution: Corrected: 2024-04-17

A person identified by the Administrator as a peer-to-peer support/volunteer was present at the operation on 2/11/24 and one other time prior, without a background check. Another citation related to this deficiency within the next 6 months may result in an additional penalty and other enforcement actions.

Resolution: Corrected: 2024-04-11

A person identified by the Administrator as a peer-to-peer support/volunteer was present at the operation on 2/11/24 and one other time prior, without a background check. Another citation related to this deficiency within the next 6 months may result in an additional penalty and other enforcement actions.

Resolution: Corrected: 2024-04-11

A service plan that identified a child as having high risk behaviors for AWOL, self-harm, and harm to others stated she did not require supervision outside the home and included no supervision requirements for the child while outside the home.

Resolution: Corrected: 2024-04-17

A service plan that identified a child as having high risk behaviors for AWOL, self-harm, and harm to others stated she did not require supervision outside the home and included no supervision requirements for the child while outside the home.

Resolution: Corrected: 2024-04-17

Operation has not had an unannounced fire drill in the last 6 months.

Resolution: Corrected: 2024-02-16

Operation has 50 % of their population as treatment services and do not have a treatment director.

Resolution: Corrected: 2024-02-16

A volunteer was observed to be at the operation did not have a personnel file.

Resolution: Corrected: 2024-02-16

A volunteer did not have a signed and dated statement to report abuse and neglect.

Resolution: Corrected: 2024-02-16

Two employee files did not have reference check screening.

Resolution: Corrected: 2024-02-16

Two employee files did not have required 40 hrs of experience or supervised experience.

Resolution: Corrected: 2024-02-16

A serious incident in which a resident became physically aggressive towards other staff and sustained an injury was not documented on a serious incident report.

Resolution: Corrected: 2024-02-16

Serious incident report did not contain necessary information required on form regarding child's gender and date of admission.

Resolution: Corrected: 2024-02-16

Operation has not had an unannounced severe weather drill in the last 6 months.

Resolution: Corrected: 2024-02-16

A volunteer did not have a signed and dated statement to report abuse and neglect.

Resolution: Corrected: 2024-02-16

Two employee files did not have reference check screening.

Resolution: Corrected: 2024-02-16

Two employee files did not have required 40 hrs of experience or supervised experience.

Resolution: Corrected: 2024-02-16

A serious incident in which a resident became physically aggressive towards other staff and sustained an injury was not documented on a serious incident report.

Resolution: Corrected: 2024-02-16

A volunteer was observed to be at the operation did not have a personnel file.

Resolution: Corrected: 2024-02-16

Serious incident report did not contain necessary information required on form regarding child's gender and date of admission.

Resolution: Corrected: 2024-02-16

Two employee files did not have reference check screening.

Resolution: Corrected: 2024-02-16

Operation has not had an unannounced severe weather drill in the last 6 months.

Resolution: Corrected: 2024-02-16

Serious incident report did not contain necessary information required on form regarding child's gender and date of admission.

Resolution: Corrected: 2024-02-16

A volunteer was observed to be at the operation did not have a personnel file.

Resolution: Corrected: 2024-02-16

Two employee files did not have reference check screening.

Resolution: Corrected: 2024-02-16

A serious incident in which a resident became physically aggressive towards other staff and sustained an injury was not documented on a serious incident report.

Resolution: Corrected: 2024-02-16

Operation has 50 % of their population as treatment services and do not have a treatment director.

Resolution: Corrected: 2024-02-16

Operation has not had an unannounced severe weather drill in the last 6 months.

Resolution: Corrected: 2024-02-16

Operation has not had an unannounced severe weather drill in the last 6 months.

Resolution: Corrected: 2024-02-16

A volunteer did not have a signed and dated statement to report abuse and neglect.

Resolution: Corrected: 2024-02-16

Operation has not had an unannounced fire drill in the last 6 months.

Resolution: Corrected: 2024-02-16

Operation has 50 % of their population as treatment services and do not have a treatment director.

Resolution: Corrected: 2024-02-16

Operation has 50 % of their population as treatment services and do not have a treatment director.

Resolution: Corrected: 2024-02-16

A volunteer was observed to be at the operation did not have a personnel file.

Resolution: Corrected: 2024-02-16

A serious incident in which a resident became physically aggressive towards other staff and sustained an injury was not documented on a serious incident report.

Resolution: Corrected: 2024-02-16

Two employee files did not have required 40 hrs of experience or supervised experience.

Resolution: Corrected: 2024-02-16

Operation has not had an unannounced fire drill in the last 6 months.

Resolution: Corrected: 2024-02-16

Operation has not had an unannounced fire drill in the last 6 months.

Resolution: Corrected: 2024-02-16

Serious incident report did not contain necessary information required on form regarding child's gender and date of admission.

Resolution: Corrected: 2024-02-16

Two employee files did not have required 40 hrs of experience or supervised experience.

Resolution: Corrected: 2024-02-16

A volunteer did not have a signed and dated statement to report abuse and neglect.

Resolution: Corrected: 2024-02-16

A volunteer was observed to be at the operation did not have a personnel file.

Resolution: Corrected: 2024-02-16

Two employee files did not have reference check screening.

Resolution: Corrected: 2024-02-16

A serious incident in which a resident became physically aggressive towards other staff and sustained an injury was not documented on a serious incident report.

Resolution: Corrected: 2024-02-16

Operation has 50 % of their population as treatment services and do not have a treatment director.

Resolution: Corrected: 2024-02-16

Operation has not had an unannounced severe weather drill in the last 6 months.

Resolution: Corrected: 2024-02-16

Operation has not had an unannounced fire drill in the last 6 months.

Resolution: Corrected: 2024-02-16

Serious incident report did not contain necessary information required on form regarding child's gender and date of admission.

Resolution: Corrected: 2024-02-16

Two employee files did not have required 40 hrs of experience or supervised experience.

Resolution: Corrected: 2024-02-16

A volunteer did not have a signed and dated statement to report abuse and neglect.

Resolution: Corrected: 2024-02-16

Two staff files did not have a current TB test.

Resolution: Corrected: 2023-12-22

Two staff files did not have a current TB test.

Resolution: Corrected: 2023-12-22

Two staff files did not have a current TB test.

Resolution: Corrected: 2023-12-22

Two staff files did not have a current TB test.

Resolution: Corrected: 2023-12-22

Two staff files did not have a current TB test.

Resolution: Corrected: 2023-12-22

Fence was observed to have exposed nails.

Resolution: Corrected: 2023-09-15

Staff hired at the operation currently does not have a pre-employment drug screen for the operation related to application.

Resolution: Corrected: 2023-09-12

Updated background check policy was not completed and approved at time of inspection.

Resolution: Corrected: 2023-10-09

Updated background check policy was not completed and approved at time of inspection.

Resolution: Corrected: 2023-10-09

Staff hired at the operation currently does not have a pre-employment drug screen for the operation related to application.

Resolution: Corrected: 2023-09-12

Fence was observed to have exposed nails.

Resolution: Corrected: 2023-09-15

Updated background check policy was not completed and approved at time of inspection.

Resolution: Corrected: 2023-10-09

Staff hired at the operation currently does not have a pre-employment drug screen for the operation related to application.

Resolution: Corrected: 2023-09-12

Fence was observed to have exposed nails.

Resolution: Corrected: 2023-09-15

Fence was observed to have exposed nails.

Resolution: Corrected: 2023-09-15

Updated background check policy was not completed and approved at time of inspection.

Resolution: Corrected: 2023-10-09

Staff hired at the operation currently does not have a pre-employment drug screen for the operation related to application.

Resolution: Corrected: 2023-09-12

2 of 2 staff files reviewed did not include in the signed statement for abuse, neglect and exploitation to include specific instructions for hotline and notifying operation.

Resolution: Corrected: 2023-06-12

Operation did not have a current health inspection.

Resolution: Corrected: 2023-06-21

Staff hired at the operation currently does not have a pre-employment drug screen for the operation related to application.

Resolution: Corrected: 2023-06-12

Operation did not have a current health inspection.

Resolution: Corrected: 2023-06-21

2 of 2 staff files reviewed did not include in the signed statement for abuse, neglect and exploitation to include specific instructions for hotline and notifying operation.

Resolution: Corrected: 2023-06-12

Staff hired at the operation currently does not have a pre-employment drug screen for the operation related to application.

Resolution: Corrected: 2023-06-12

Operation did not have a current health inspection.

Resolution: Corrected: 2023-06-21

Staff hired at the operation currently does not have a pre-employment drug screen for the operation related to application.

Resolution: Corrected: 2023-06-12

Operation did not have a current health inspection.

Resolution: Corrected: 2023-06-21

2 of 2 staff files reviewed did not include in the signed statement for abuse, neglect and exploitation to include specific instructions for hotline and notifying operation.

Resolution: Corrected: 2023-06-12

Staff hired at the operation currently does not have a pre-employment drug screen for the operation related to application.

Resolution: Corrected: 2023-06-12

Operation did not have a current health inspection.

Resolution: Corrected: 2023-06-21

2 of 2 staff files reviewed did not include in the signed statement for abuse, neglect and exploitation to include specific instructions for hotline and notifying operation.

Resolution: Corrected: 2023-06-12

2 of 2 staff files reviewed did not include in the signed statement for abuse, neglect and exploitation to include specific instructions for hotline and notifying operation.

Resolution: Corrected: 2023-06-12

Staff hired at the operation currently does not have a pre-employment drug screen for the operation related to application.

Resolution: Corrected: 2023-06-12