PRLU or OLTC
Recommendation for Probationary License
PRLU or OLTC
Complaint, Licensing Follow Up, Notice of Incident, Visit Compliance Report
- Licensing (Complaint)
- Complainant stated 2 staff members withheld water from the orange unit as a punishment. When asked for by the residents, staff stated they were withholding it until the residents calmed down. Complainant stated a staff member does not give bathroom breaks and makes staff wait for over an hour, indicating they are still assigning only 1 staff per dorm. Complainant reported a staff member yells and berates residents and puts residents and staff at risk (e.g.: She told a staff member to stand in a resident’s room alone while they shower and do “Marco Polo”; She told 2 staff members to completely ignore a kid if they appear to be having a seizure; She tells new staff that orientation kids can immediately sleep in their rooms instead of in the dayroom for the required 5-7 days of Constant LOS).
- Licensing follow-up: Specialist requested additional information and work schedules of staff named in complaint. As of 10/31/22, facility reported the first staff member is no longer with the agency (terminated for improper use of a restraint), and the second staff member will be doing administrative duties until further notice. Licensing visited facility on 11/3/22 and interviewed 4 residents; When asked if there were any concerns regarding staff members, both staff were mentioned. Specialist interviewed staff still employed, who stated she felt like she was retaliated against for writing up a staff member. On 11/15/22, facility DON informed specialist that documentation of the write-up that the alleged staff member completed on an employee had not been produced. No licensing concerns noted. Complaint unfounded.
PRLU or OLTC
Complaint Visit, Visit Compliance Report
- Licensing Specialist: Kendra Rice.
- Facility visited from 9:15pm – 9:55pm; Census: 29. Licensing received a complaint on 10/12/22 that a resident had been sleeping on the floor. It was reported to Licensing Specialist on 10/19/22 that resident stated they did not have a room and sleeps on a mattress in the dayroom. Licensing completed walkthrough of the green unit and observed resident on a mattress in the dayroom due to being placed on “line of sight” on 10/24/22. All other residents were observed in bedrooms. Licensing reviewed MARs for 5 residents with no licensing concerns noted.
Police Report
911 Hang Up, Call Report
Caller advised dispatch “Behavioral Health on 7th St” and the call disconnected. Call was accidental; No action taken.
Medicaid Inspection of Care
Inspection of Care Report
- Included: IOC, CAP
- Multiple deficiencies noted. CAP must be completed within 30 calendar days (CAP submitted).
PRLU or OLTC
Licensing Follow Up, Notice of Incident, Self-Harm
- Licensing (Self-harm)
- Client was disrespectful in class and became frustrated after being redirected by staff. Client slammed her fist on the desk and stabbed her arm with a pencil. The pencil was immediately removed, and client agreed to take her PRN medication after processing with staff. Nurse assessed client and noted 2 superficial puncture marks on her arm with no bleeding; No first aid needed. Client completed CSSR and discussed with therapist. Client placed on misconduct safety plan.
- Licensing follow-up: Specialist was informed the client was cooperative and participated in class on 10/21/22. No licensing concerns noted.
PRLU or OLTC
Personnel Record Review, Visit Compliance Report
- Licensing Specialist: Chelsea Vardell.
- Facility visited from 1pm – 4:30pm. Census: 28. Licensing completed a background check review of 20 staff. Background checks prior to the new HR director beginning in June 2022 were seen missing or not done in the correct timeframe. This issue was already previously addressed by licensing. Licensing also reviewed the incident notification log for incidents from 10/6/22 – 10/19/22, the restraint log for restraints from September and October 2022, and nightly visual observation logs of residents from the green unit for the past 2 weeks.
- Licensing also completed a courtesy follow-up with a resident, who stated he sleeps in the dayroom on a mattress and is not allowed to have his own room. Licensing spoke with staff, who stated the resident was sleeping in the dayroom due to sexualized behavior towards others. The resident has since been placed in his own room with no roommates.
- TA –
- 103.10 – The background checks for the new CEO were not in his personnel file for review.
Police Report
Drugs
Staff advised a resident had a marijuana vape that she got from her guardian. Officer responded and seized the vape pen. Facility is unsure whether they want to press charges; Officer provided facility with report number.
PRLU or OLTC
Children's Records Review, Personnel Record Review, Visit Compliance Report
- Licensing Specialist: Kendra Rice.
- Time of visit: 11:30am. Census: 49. Licensing reviewed 3 resident files and 3 personnel files.
- Regs out of compliance –
- R903.4 – Resident treatment plans were not developed within 30 days after being placed at the facility.
- R105.13 – Staff member did not have documentation of annual training. HR agreed to have documentation in the majority of the personnel files by 11/18/22.
PRLU or OLTC
Contraband, Licensing Follow Up, Notice of Incident
- Licensing (Contraband)
- A vape was found concealed in a client’s deodorant after client returned from a weekend pass with her family. Client stated the vape contained THC and was stolen from her mother’s purse. Client was exhibiting common behaviors associated with being under the influence of marijuana and will be monitored by staff. Client was placed on misconduct safety precautions for 7 days. Police were called; Facility will be making necessary corrections in procedure regarding hygiene inspections.
- Licensing follow-up: Specialist inquired of body and personal hygiene checks and was provided with the policies for Therapeutic Passes and Body Safety Checklist. No licensing concerns noted.
PRLU or OLTC
Complaint, Licensing, Notice of Incident
- Licensing (Complaint)
- Complainant reported there not being enough staff per resident ratio on many occasions, and stated they were working alone on a unit with 9 residents. Complainant stated they witnessed several fights in the last week that caused major concerns for the residents and stated, “They do not provide a therapeutic environment to the residents.”
- Licensing follow-up: On 11/3/22, Specialist received a staff roster for 10/2/22 – 10/6/22. Specialist will arrange to talk with residents on the Blue Unit. Complaint unfounded.
PRLU or OLTC
Self Report Visit, Visit Compliance Report
- Licensing Specialist: Kendra Rice.
- No site visit conducted. Licensing received 2 incidents on 10/06/22 that happened on 09/27/22 and 09/30/22. The facility is in violation of their corrective action agreement by not reporting the incidents to licensing per agreement.
- Regs out of compliance –
- R110.17 – Incident on 09/27/22 and incident on 09/30/22 were not reported until 10/06/22.
Police Report
Hang Up
Caller advised he didn’t mean to dial 911, and there were no emergencies.
PRLU or OLTC
Notice of Incident, Peer Altercation, Self-Harm
- Licensing (Peer Altercation, Self-harm)
- Client was irritated by behavior of peer in class and punched peer in the face. Peer had been hitting her face on her desk when client assaulted her. Peer sustained laceration around eyebrow and bruise/swelling around the eye and cheek; First aid was applied. Client was immediately escorted out from the classroom and processed with staff; Client was placed on assault safety plan for 7 days. Peer processed with her therapist and was placed on self-harm and misconduct precautions.
- Licensing follow-up: No licensing concerns noted.
PRLU or OLTC
Licensing Follow Up, Notice of Incident, Suicide Attempt
- Licensing (Suicide Attempt)
- Client attempted to use sweatpants as a neck ligature when using the restroom. Staff noticed client take them into the restroom and called for support, and staff removed the sweatpants from client. No injuries occurred. Client placed on suicide risk safety precautions.
- Licensing follow-up: Facility will be cited for R110.17 (incident occurred on 9/30/22 and was not reported until 10/6/22).
Police Report
Disorderly Conduct
Caller reported a juvenile had a vape pen and was vaping on the premises.
PRLU or OLTC
Buildings and Grounds, Visit Compliance Report
- Licensing Specialist: Kendra Rice.
- Facility visited from 1:55pm – 2:45pm; Census: 31. Walkthrough completed of Blue and Orange Units and outside. Bedroom #103 (Blue) and Bedroom #201 (Orange) was rough around the shower drain and a screw was sticking out around the shower drain in Bedroom #204 (Orange). Maintenance was made aware and stated epoxy would be applied to drain areas.
- TA –
- R910.1 – Disposable cups were observed in the outside play area (removed by maintenance).
- R911.6 – Missing paint was observed throughout Blue and Orange Units (maintenance stated they are getting ready to paint the units).
PRLU or OLTC
Licensing Follow Up, Notice of Incident, Self-Harm
- Licensing (Self-harm)
- Client became dysregulated on unit and charged at peer after a verbal disagreement. Staff intervened and removed peers. Client began throwing chairs and tables, and self-harming using game pieces to rub on her forearm. Client was placed in a restraint after hitting, kicking, and spitting at staff who attempted to get game pieces from client. No injuries were sustained. Client took PRN medication and processed with staff. Client was placed on assault precaution for additional days.
- Licensing follow-up: Specialist was informed by the DON that client did not verbally state she wanted to self-harm. The facility is in violation of their corrective action agreement.
Police Report
Sex Offenses
Juvenile reported a peer raped her at least twice in the last 2 months. Juvenile stated peer “fingered her vagina and anus and performed sex on her.” Juvenile and peer have been separated into different units and will no longer have contact. Upon being interviewed, juvenile stated she did not want to report this and didn’t want peer to get in trouble. Investigator received notes that were reportedly from juvenile to peer, asking peer to rape her and that she needed to do so without notice or warning. The other note was from peer to juvenile, stating she fucked up and the fact that she did not stop when juvenile said stop made it rape. The case will be closed due to juvenile not wanting to press charges and statement she made in the interview contradicts the note she wrote to peer.
PRLU or OLTC
Complaint, Notice of Incident, Visit Compliance Report
- Dual (Complaint)
- Licensing received an email from a former employee, who quit due to a “continuing refusal by upper management to report incidents as required.” Complainant reported a specific incident on 9/25/22, in which a CNA took a resident down to the floor in what appeared to be a “very inappropriate restraint” after being assaulted by resident. The resident and CNA both sustained superficial scratches. After video footage was reviewed, the CEO determined there to be no need to report the incident. Complainant disagreed and submitted a letter of resignation, stating “I could no longer continue in a position I felt was making me compromise my values and fight my superiors almost daily. This has been an on-going issue since day 1.”
- Licensing follow-up: Licensing was informed the CNA involved is no longer employed with facility, and the facility will no longer use Shift Key (an outside contractor). Camera footage was reviewed on 10/03/22 and showed staff out of ratio on the green unit on 9/25/22 (1:10). Staff approached client after client threw crackers at staff, at which point client punched staff. Staff attacked client and placed her arm around client’s neck and slammed her to the ground. Other staff entered unit while staff and client were on the floor. Staff could be seen laying across the client’s mid-section of her body. Referral #2169574 was screened out. Outcome: Founded.
- Licensing cited facility for the following:
- R109.1.g – Staff engaged in unprofessional conduct that can be viewed as physically harmful to a resident.
- R905.9 – Staff did not use the minimal force or time necessary during the restraint hold.
- R907.3 – Staff was out of ratio 10:1 on the green unit.
- R110.9 – Facility failed to report to the child abuse hotline.
- R105.3 – Staff did not receive preservice training before being counted in staff/child ratio.
- R105.7 – Staff participated in a restraint hold of a resident prior to being trained in SAMA.
- R103.1 – Staff did not have all the required background checks conducted before working on the floor with residents.
PRLU or OLTC
Notice of Incident, Sexual Contact
- Dual (Sexual Contact)
- Client made allegation of sexual misconduct involving peer as the initiator. Per client description, this incident took place months ago and there are no recent events to report. Clients were separated and put on different units.
- Child Abuse Hotline was called and accepted. Outcome: Founded. Licensing follow-up: Facility will be cited for R110.12. Licensing complaint is unfounded for any supervision concerns but founded for failing to report the incident to the licensing unit by the next business day (incident occurred on 9/25/22 and was not reported until 10/5/22).
Police Report
Hang Up
Complaint only.
PRLU or OLTC
Corrective Action Visit, Visit Compliance Report
- Licensing Specialist: Kendra Rice.
- Facility visited from 1130 – 1315. Census: 27. Licensing completed a walkthrough of the Orange and Green Halls, and MARs were reviewed for 5 residents.
- TA –
- R911.6 – Some of the shower floors on the Orange and Green Halls have roughness around the drain. Maintenance was made aware of the licensing concern and agreed to take care of the concern. Licensing will follow-up with the facility on 9/19/22.
PRLU or OLTC
Licensing, Notice of Incident, Suicide Attempt
- Licensing (Suicide Attempt)
- Client became dysregulated due to peers being too loud and tied her shirt around her neck as a ligature. Staff removed the shirt and brought client off the unit to calm down and process with staff. Client was given paper scrubs and will be placed on a 7-day self-harm precaution safety plan with increased line of sight.
- Licensing follow-up: No licensing concerns noted.
Police Report
Hang Up
Dispatch received abandoned 911 call from facility; Upon call back, facility advised there was no emergency.