A validation survey was conducted from 10/3/22 – 10/7/22. No deficiencies were cited.
PRLU or OLTC
Recertification Survey
PRLU or OLTC
Monitor Visit, Visit Compliance Report
- Licensing Specialist: Clayton DeBoer.
- Buildings & Grounds conducted from 12pm – 1pm. Census: 23. Licensing reviewed areas where deficiencies were cited on 9/20/22 and noted repairs made to multiple rooms/areas and repairs still pending. MARs checked for 5 residents.
PRLU or OLTC
Monitor Visit, Visit Compliance Report
- Licensing Specialist: Clayton DeBoer.
- Facility visited from 1:15pm – 3:45pm. MARs checked with no concerns. Progress visits will be conducted as to ascertain improvements are being addressed.
- Regs out of compliance –
- 9.911.6 – Window trim and holes in wall in rm 2. Hole under A/C unit and broken door handle in rm 4. Light switch needs replaced and wall is rotten in rm 5. Broken sink shroud, smoke detector hanging from ceiling, and holes in drawers in rm 6. Hole in the wall in the bathroom and broken toilet seat in bathroom in rm 8. Loose board over vanity in rm 23. Broken door to bathroom, A/C unit needs a screen, and silver wall plate is missing exposing a screw and wires in rm 28. Screw poking out of wall and A/C unit needs cover in rm 29. Missing floor tile in rm 30. Top to toilet is broken, hole in wall, and A/C not fitted to wall in rm 63. Screws poking out in bathroom in rm 65. A/C vent cover is missing in rm 67. Wallpaper is pulled from the wall above headboard in rm 68. Missing floor tile in bathroom in rm 69. Ropes on dressers are dirty and shall be replaced to all the drawers to be used designed. Boys and girls shower areas have broken doors. Wood/metal picnic tables in outside area broken with sharps exposed (wood or metal is sharp). Cracked/broken dirty clothes baskets shall be replaced. Broken and sagging ceiling tiles shall be replaced.
- 9.912.4 – Boys and girls shower areas have stained mats outside of showers, rust on black metal below the showers, black mats have white build up on them.
- 9.913.5 – Several bedrooms were missing pillows. All bedframes shall be secured to the floor to prevent them from moving (beds are screwed into the floor).
- 9.911.15.d – Exposed tv/electronic wires need to be covered and/or neatly wrapped up in rm 22 (Dayroom).
PRLU or OLTC
Monitor Visit, Visit Compliance Report
- Licensing Specialist: Clayton DeBoer.
- Facility visited from 6:00pm – 7:00pm. Census: 19. MARs checked for 5 residents. No licensing concerns noted during visit.
PRLU or OLTC
Buildings and Grounds, Visit Compliance Report
- Licensing Specialist: Clayton DeBoer.
- An unannounced visit was conducted from 12:30pm – 1:30pm. Census: 17. MARs checked for 5 residents. No licensing concerns noted during visit.
PRLU or OLTC
Visit Compliance Report
- Licensing Specialist: Clayton DeBoer.
- Facility visited from 10:30am – 11:30am. Census: 20. MARs reviewed for residents. No licensing concerns noted during visit.
PRLU or OLTC
Children's Records Review, Personnel Record Review, Visit Compliance Report
- Licensing Specialist: Clayton DeBoer.
- Specialist visited facility from 11:30am – 2:30pm. Records reviewed for 5 residents and 10 staff; No licensing concerns noted.
PRLU or OLTC
Complaint Survey with POC, Revisit Survey
- Complaint #AR00027919 was unsubstantiated.
- Regs out of compliance –
- N 120 – Facility failed to meet the requirements for Condition of Participation by failing to ensure a policy and procedure related to the vaccination of staff, appropriate interventions were in place to mitigate the spread of Covid-19, and only 53 percent of staff were vaccinated.
- N 156 – Facility failed to ensure a Physician’s order for a physical restraint was signed by the physician for 1 client who was physically restrained.
- Plan of Correction – Policy was implemented (IC35/Employee Health COVID Control Plan) and database developed to track vaccination status of staff. The attending physician was retrained regarding CMS guidelines and DFC Policy PC 11, and DocuSign program was purchased and activated to expedite signatures. The Director of Nursing will in-service all nursing staff on policies and DocuSign application and will review each seclusion and restraint to ensure signatures.
- A revisit was conducted on April 19, 2022, for all deficiencies cited on March 10, 2022. All deficiencies have been corrected, and no new noncompliance was found.
PRLU or OLTC
Notice of Incident
- Maltreatment
- Client disclosed that staff member roughly placed her in a restraint, resulting in client having a black eye, scratches to the neck, and bruises to the arm. Client still has the scratches/bruising on her arm, but the black eye has faded (she could not see out of her eye for “awhile”). Staff members have been calling her “Chucky” and client is not allowed to have unsupervised phone calls with her DHS caseworker (a therapist must be present). Reported to DCCECE on 2/24/22.
- Child Abuse Hotline was called and accepted. Agency’s Corrective Action: “Clients who were arguing separated.” Specialist visited facility on 2/28/22. Report indicated that client’s belongings were removed after client threatened staff. Video was reviewed which showed no inappropriate holds. The incident was reported to Licensing 2 days after facility was aware of the hotline call. Facility was cited for 110.12.
PRLU or OLTC
Visit Compliance Report
Census: 22. Buildings and Grounds conducted; No regs out of compliance. MARs checked for 5 residents.
PRLU or OLTC
Visit Compliance Report
Buildings and grounds conducted; MARs checked for 5 residents. No concerns noted.
Medicaid Inspection of Care
On-Site Inspection
- Included: IOC, CAP
- Multiple deficiencies noted. Plan of Correction required to be completed within 30 days.
PRLU or OLTC
Visit Compliance Report
- Specialist conducted buildings and grounds visit; Census is 22 kids. Specialist reviewed MARs for 8 residents with no issues found.
- Regs out of compliance –
- R911.6 – Switch plate in room 68 bathroom is broken/cracked and needs to be replaced.
PRLU or OLTC
Notice of Incident
- Maltreatment – Sexual Abuse
- Former resident of facility disclosed that she was sexually molested by a staff member and tied up against her will. She reportedly told the therapist at the facility and then she was punished by the person who had molested her, and it was hidden by the therapist.
- Child Abuse Hotline was called and accepted.
PRLU or OLTC
Visit Compliance Report
- Reviewed 5 personnel records, no regs out of compliance.
- Regs out of compliance (Building & Grounds) –
- R912.4 – Room 8 bathroom needs cleaning and had a clogged toilet. Due date 5.21.21
- R911.6 – Room 70 with hole in wall. Missing ceiling tiles in Classroom 1. Room dresser drawer missing bottom of shelf. Due date 5.31.21
- R913.5 – Room 67 mattress in need of replacing. Due date 6.15.21.
- TA –
- R908.8 – Delay of signing off medication from the nurse med log.
PRLU or OLTC
Visit Compliance Report
- Regs out of compliance –
- R911.15.f – Strings/cords found on minors clothing in the following rooms: 177, 152,156, & 202. Corrected 5.19.21.
- TA –
- R911.6 – Bathroom shower wall was peeling and in need of repair (repairs were in progress).
PRLU or OLTC
Visit Compliance Report
- Regs out of compliance –
- R911.6 – Ensure light cover is replaced; Observed broken light cover with jagged edge. Ensure large hole in bathroom wall is repaired. Ensure bathroom door is replaced; Top half of door is missing with only part of outer shell showing. Ensure outside glass door to administration hall is replaced; Glass door is severely cracked.
PRLU or OLTC
Licensing Compliance Record
- Ratios observed 1:5 boys hall, 1:6 boys hall, 2:11 girls’ hall (quarantined)
- Last fire drill completed 11/18/20, emergency drill 10/29/20, health inspection completed 08/20/20. Facility told specialist on 8/10 health inspection had already been done.
- TA – large trashcans in boys bathroom beginning to crack around the top. Each positive COVID case shall be reported to licensing.
PRLU or OLTC
Licensing Compliance Record
- Specialist: Shannon Rouse
- Reviewed med logs and emergency drills. Collected 2020 annual documentation. 2020 health inspection done, waiting on documentation from health dept. reviewed 14 staff background checks.
- 914.9 – Reg not correctable – drill shall list number of participants and length of time to reach safety
PRLU or OLTC
Licensing Compliance Record
- Viewed all areas of building used by children. Several holes in walls.
- 911.6 x6 – holes in wall, hole exposing electrical outlet, vent hood is leaking, toilet seat needed, ceiling tile needs replacement.
- TA given on holes in wall – agency working to cover walls with boarding by April 2020.
PRLU or OLTC
Complaint Survey
Complaint Survey (#AR00023844). Unsub.
PRLU or OLTC
Complaint Survey
Complaint Survey requiring POC, 10.09.19 Complaint Survey with POC embedded.
PRLU or OLTC
Licensing Compliance Record
- Reviewed 11 personnel files. 2 needed 3 personal references. Compliance date and date corrected listed as 08/10/19 for both.
- Viewed boys and girl’s halls and all areas used by children on halls with no safety concerns cited.
PRLU or OLTC
Licensing Compliance Record
- Viewed all areas of building and grounds used by children with no safety concerns noted.
PRLU or OLTC
Complaint Survey, Revisit Survey
Complaint Survey requiring POC (#AR00022508) USE OF RESTRAINT AND SECLUSION
- 03.14.19 Revisit for all deficiencies cited on 01.29.19