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- Licensing Specialist: Michele Sutton and Chelsea Vardell.
- Licensing Specialist reviewed records for 5 children and 11 staff. Licensing viewed fire drills and storm drills; Facility was in compliance with safety requirements. Licensing conducted a brief walkthrough of the milieu area, and facility has implemented a “Shout out” bulletin for staff and residents to write encouraging messages, added wallpaper to common area, and implemented a “Feelings Wheel” on units to assist residents with processing their emotions with staff.
- Regs out of compliance –
- 904.1.h – Copy of social security card or documentation it has been requested needed for 1 resident.
- 904.1.i – Copies of immunizations or documentation they have been requested needed for 1 resident.
- 105.3 – All pre-service documentation was not documented in all 11 personnel records.
- 105.13 – Training documentation shall include date, hours, topic, and source. Training records for all 11 personnel only contained the date and topic of training.
- 105.10 – Each personnel file shall have 10 hours of psychiatric specific training before being counted in the staff/child ratio. All 11 personnel records did not have 10 hours documented.
- 107.4 – Personnel records should include documentation that they have been made aware of the need to protect the confidentiality of children in the use of social media. Documentation was only found in 1 of 11 personnel files viewed.
- 103.2.a – AR Child Maltreatment regulatory check was not initiated within 10 days of hire for 1 personnel. (CEO reports this is likely due to termination of HR Director on 01/09/23).
- 105.15.h – 10 personnel records did not have 3 references from non-relatives in their file.
- TA –
- 105.15.c – Please ensure all personnel have some form of verification of their qualifications (high school diploma, GED, or college diploma).
