- Licensing Specialist: Clayton DeBoer.
- Personnel Records Check from 10am – 12pm for 10 employees. No licensing concerns noted.
PRLU or OLTC
Personnel Record Review, Visit Compliance Report
PRLU or OLTC
Monitor Visit, Visit Compliance Report
- Licensing Specialist: Clayton DeBoer.
- Buildings & Grounds conducted from 10am – 11:30am. Census: 23. Classroom, outdoor area, Units 1 & 2, and residential sleeping area observed. MARs checked for 5 residents. No licensing concerns noted.
PRLU or OLTC
Complaint, Notice of Incident, Visit Compliance Report
- Complaint
- A parent reported child abuse (molestation) at facility. Parent reported her son was not abused that she was aware of, but she would be taking him to the doctor to make sure.
- Licensing follow-up: Licensing contacted complainant who reported medication issues, complained of a staff member at an acute facility, stated a child was molested at Centers, complained about a lady telling her child how to wash his butt, and requested help regarding a Medicaid waiver. Licensing informed complainant that the licensing unit does not handle Medicaid waivers. The hotline report was screened out due to the complainant not having any details regarding the molestation complaint. The complainant’s concern is with her child’s current school, which is not connected to the facility directly. Due to lack of evidence, no names of witnesses, dates, or descriptions of the incident, this complaint is unfounded.
Medicaid Inspection of Care
Inspection of Care Report
- Included: IOC
- No deficiencies noted
PRLU or OLTC
Monitor Visit, Visit Compliance Report
- Licensing Specialist: Clayton DeBoer.
- Buildings & Grounds conducted from 10:30am – 11:30am. Census: 22. Classroom, outdoor area, and 2 areas with clients observed. MARs checked for 5 residents. No licensing concerns noted.
PRLU or OLTC
Monitor Visit, Visit Compliance Report
- Licensing Specialist: Clayton DeBoer.
- Buildings & Grounds conducted from 1pm – 2pm. Census: 23. Sleeping areas, day areas, cafeteria, bathrooms and grounds observed. MARs reviewed for 5 residents. No licensing concerns noted.
PRLU or OLTC
Monitor Visit, Visit Compliance Report
- Licensing Specialist: Clayton DeBoer.
- Facility visited from 7:00pm – 8:00pm. Staff/client ratio: 5:22. MARs checked for 5 residents.
- Regs out of compliance –
- 9.911.15.f – Unit 1 (Boys Hall) had one pair of shorts with tie-string sewn in. The string could be pulled out over a foot in length. Staff acknowledged this was not allowed and the shorts were removed.
PRLU or OLTC
Visit Compliance Report
- Licensing Specialist: Not listed.
- Facility visited from 11:30am – 1:00pm. Census: 20. MARs checked for multiple residents. No licensing concerns noted during visit.
PRLU or OLTC
Notice of Incident
- ER Visit (Accidental Injury)
- Client fell while playing on monkey bars and complained of pain to her right arm. Client was evaluated by medical staff after incident, and again that evening. The next morning, client was sent to ER for an x-ray. ER x-ray results: Buckle fracture to left wrist. Client’s left arm was placed in a partial cast, and follow-up appt. scheduled. Client’s guardian reported client had sustained the same fracture, to the same wrist, while playing at school the previous month.
PRLU or OLTC
Visit Compliance Report
- Licensing Specialist: Clayton DeBoer.
- Census: 23. Buildings and grounds conducted from 12:00pm – 1:30pm: Hall 1 bathroom motion sensor battery out for sink faucet. Maintenance addressed this during visit. MARs checked for 5 clients; No licensing concerns noted.
Medicaid Inspection of Care
Inspection of Care Report
- Included: IOC, CAP
- Deficiencies noted. Plan of Correction required to be completed within 30 days.
PRLU or OLTC
Visit Compliance Report
Census: 22. Buildings and grounds conducted, and MARs checked for 5 clients. No licensing concerns noted. The cafeteria is getting new windows tomorrow.
PRLU or OLTC
Visit Compliance Report
Census: 23. Buildings and grounds conducted, and MARs checked for 5 clients. No licensing concerns noted.
PRLU or OLTC
Visit Compliance Report
Buildings and grounds visit; Issues from last visit have been corrected. MARs were checked and no issues were found. The facility was clean and well kept.
Medicaid Inspection of Care
On-Site Inspection
- Included: IOC (revised), Reconsideration Determination Letter
- Multiple deficiencies noted. Plan of Correction required to be completed within 30 days.
PRLU or OLTC
Revisit Survey, Validation Survey with POC
- Regs out of compliance –
- E 004 – Facility failed to ensure a comprehensive emergency preparedness (EP) plan was reviewed and updated at least annually and operationalized to prepare for resident and staff safety in the event of a potential emergency or disaster situations.
- Plan of Correction – EP plan will be developed by 11.19.21 and will be reviewed every 2 years or sooner if any changes are needed.
- During the Revisit Survey conducted on 11/29/21, the facility was found to be in compliance with program requirements.
PRLU or OLTC
Visit Compliance Report
- No regs noted out of compliance. Specialist reviewed med logs for 4 kids with no issues found.
- TA –
- R912.6 – No toilet tissue was found in two of the bathrooms. Staff was notified and this was corrected on site.
PRLU or OLTC
Complaint Survey with POC, Revisit Survey
- Complaint #AR00026550 unsubstantiated.
- Regs out of compliance –
- N 148 – Facility failed to ensure specific time limit for restraint order was on the physician’s order for 3 clients who had ESI orders.
- N 165 – Facility failed to ensure a client placed in a physical restraint was continuously monitored for physical/psychological well-being for Client #1.
- N 167 – Facility failed to ensure a physician or permitted licensed practitioner evaluated the resident’s well-being immediately after the restraint was removed for 2 clients.
- Plan of Correction – Ten-minute time limit placed on all physician orders; Re-training on ESI monitoring and evaluations after ESIs.
- A revisit was conducted for all deficiencies cited on 05.13.21; All deficiencies have been corrected and no new noncompliance was found.
- Survey Team Composition and Workload Report –
- Surveyor 1 onsite 11.5 hours 8am – 6pm; 5.5 travel hours, 1 off-site report prep hours (05/11/21 – 05/13/21).
- Surveyor 2 onsite 11.5 hours 8am – 6pm; 8.5 travel hours, 5.5 off-site report prep hours (05/11/21 – 05/13/21).
- One surveyor onsite 5.5 hours 8am – 6pm; 6.5 travel hours, 1 off-site report prep hours (07/01/21).
PRLU or OLTC
Notice of Incident
- Injury – Staff Abuse
- While client was playing basketball with peer, staff thought client was being too aggressive and believed to restrain client. Client reported that Staff put him in a restraint and threw him against plexiglass where it left a bruise on an unknown part of client’s body. Client reported that staff grabbed his arm and pressed his fingers in his arms leaving red marks, however it is unknown when that happened or if it left injuries at the time. No follow-up details.
PRLU or OLTC
Visit Compliance Report
- Regs out of compliance –
- R911.15.f – Viewed drawstrings in clothing items on unit 1 and 3.The items were removed from the units during the walkthrough. Corrected 4.27.21.
- TA –
- R908.8 – One medication was not documented as given; all others had documentation of nurse giving medication. Facility stated they are using a new electronic system and if it is not signed off on in a certain amount of time, the option to sign disappears. The facility will discuss with IT getting the time frame for signature changed.
- R910.1 – Viewed missing lower board on the left side of the fence, the board needs repaired or replaced.
PRLU or OLTC
Notice of Incident
- Elopement
- Clients 1 & 2 were participating in a kickball game in front of the facility when both clients ran into the woods. Staff attempted to stop them and were unable to catch them. Client 1 was found by Monticello PD at 8:30 pm; Client 1 was unharmed and placed on elopement precautions.
- Agency was contacted for information on Client 2.
Police Report
Runaway
Officer dispatched to facility for 2 Runaways; Staff stated the 2 Juveniles walked away from facility into the woods. Officers circulated the area with negative results. Both Juveniles were later found in the late evening of 4/19/21 and early morning of 4/20/21.
Police Report
Fire Alarm
Fire Department was contacted; Alarm company called back to cancel.
Police Report
Other
New arrival at facility; Juvenile escorted by DHS, refusing to go in facility.
PRLU or OLTC
Licensing Compliance Record
- 912.4 – areas with rust and mildew in bathroom on hall 3. No corrected date listed.
- 908.6 – Ensure all controlled substances are double locked. Second lock in medication room unlocked at time of visit.
- 911.15.f – Clothing items with drawstrings found in 3 children’s rooms.
- 604.1g – need BC for resident, need court order for resident.
- 904.1.i – immunization record not on file for resident.
- 908.8 – not correctable – ensure medication is logged as dispensed.Noon dose not logged.