Abundance of Joy Home Shelter

Staff are allowing children in care to fight without intervening.

Anthony Baldwin DOH: 6-17-24 748.505(5)-No Affidavit Form 2912 in file

Staff Anthony Baldwin left the operation and went to work for another place not related and came back 2 years later. He had no updated TB test in file since being unemployed by a regulated operation within the previous 12 months.

Staff Anthony Baldwin No verification in file that employment history or reference checks were completed

Anthony Baldwin DOH: 6-17-24 748.505(5)-No Affidavit Form 2912 in file

Staff Anthony Baldwin left the operation and went to work for another place not related and came back 2 years later. He had no updated TB test in file since being unemployed by a regulated operation within the previous 12 months.

Staff Anthony Baldwin No verification in file that employment history or reference checks were completed

A single caregiver was observed to be present with seven children in care.

The operation has an active background check for staff that no longer works for the operation.

Prudent judgement was not demonstrated when children in care were asked to write a reference letter for a caregiver caring for the children.

1 of 2 direct staff did not have psychotropic medication training.

2 children's service plans did not have the parent's signature.

1 of 2 direct staff did not have psychotropic medication training.

2 children's service plans did not have the parent's signature.

Recreational calendars provided for the past 90 days did not outline an indoor & outdoor recreational activity.

There is no record of practice severe weather drills.

Medication logs reviewed, show no record of medication that was administered.

During the course of the investigation, a child in care reported not being able to breathe during a restraint involving staff sitting on them. The child reported breathing heavily once released. Three children interviewed also reported hearing the child say they could not breathe.

During the course of the investigation, it was reported that staff sat on a child?s lungs and belly during a restraint. Three children interviewed corroborated the child's statement.

Several staff members failed to complete required training prior to being counted in ratio.

One out of three employee files reviewed only contained 34 annual training hours instead of the required 50 hours.

One out of four youth files reviewed did not contain all required documentation detailing a youth's discharge.

Two out of four youth files reviewed did not include known contrindications to restraints for the youth.

One of three youth files reviewed did not contain a signature by the PLSP on the most recent service plan.

The administrator did not have all required annual trainings.

One out of three employee files reviewed only contained 34 annual training hours instead of the required 50 hours.

One out of four youth files reviewed did not contain all required documentation detailing a youth's discharge.

Two out of four youth files reviewed did not include known contrindications to restraints for the youth.

One of three youth files reviewed did not contain a signature by the PLSP on the most recent service plan.

The administrator did not have all required annual trainings.

A caregiver took five children in care, ages 9-13, to see a horror movie rated PG-13. Several of these children have history of self-harm and have experienced significant trauma. One child?s Conservatorship worker stated that due to her diagnosis, her mindset is much younger than her age.

During an inspection at the operation, scissors were observed to be accessible in a drawer to youth in care recently after an incident involving scissors occurred with a youth at the operation.

The operation has not entered EBI data in their provider portal for Quarter 4 of 2023.

A suicide risk screening was not conducted with a child post returning from the psych hospital.

Four out of four fire/evacuation drills reviewed were not completed within the required three minutes. One out of the four drills reviewed did not indicate the smoke alarm was set off.

It was found in 2 out of 3 children files reviewed that no child orientation was provided upon admission.

A serious incident that was reported to the statewide intake hotline by the operation did not have a coinciding report documented at the operation.

It was found that 2 out of 3 staff records that there was no high school diploma or GED in the file.

Two out of three child records reviewed did not contain a signed statement to acknowledge the child's rights.

One out of three child files reviewed did not contain a copy of the initial service plan in the file. Two out of three children's files did not contain the most recently updated service plan in the file.

One out of seven employee files reviewed did not contain an updated professional licensure as required for their job position nor any record of training completed. Another employee file did not contain a job description.

The last validation of the employee list in the provider portal was four months ago.

The operation has not had an administrator in 90 days.

The operation has not had an administrator in 60 days.

A window blind in one of the bedrooms was damaged.

One of two bathroom had a broken toilet paper holder. There was an exposed electrical socket in the kitchen dinning area.

A window blind in one of the bedrooms was damaged.

Two of two bathrooms utilized by children in care did not contain: paper towel or any hand drying agent. One of two bathrooms did not contain toilet paper, One of two bathrooms had a broken vanity exposing piping. One of two bathroom had a broken toilet paper holder. There was an exposed electrical socket in the kitchen dinning area. There was bag of meat in the freezer in a ripped bag exposing the meat. There was a clump of hair in the freezer.

The purpose of this standard is to ensure child care regulation is able to assess records and documentation for accuracy and compliance.

A window blind in one of the bedrooms was damaged.

Two out of two restraints reviewed did not include a notification to the parent.

One out of three medication records reviewed indicate that the medication count was inaccurately logged.

During the inspection, two out of three restraint reports had missing post discussion documentation.

A window blind in one of the bedrooms was damaged.

One out of three medication records reviewed had signatures documented/signed prior to administering any medication to children in care.

annual summary log was not given to inspector regarding AWOL as requested

There was no documentation sent to inspector regarding EBI being performed on victim and documentation on EBI performed on other children in care who were interviewed

No serious incident report was given to inspector regarding AWOL of victim that was called in to licensing

Operation did not send any post EBI documentation regarding the victim or any child in care from the operation

No debriefing documentation was given to inspector regarding AWOL of victim

Reviewing staff training 5 out of 8 staff do not have up to date training for EBI

Due to 5 out of 8 staff EBI records no being current. 5 staff are not qualified to perform EBI.

The operation documents on their incident reports that children are being evaluated by their concierge doctor however there is not always documentation to go along with this and when a document is provided it does not have any official signatures or letterhead and it is unknown who is filling out the document .

Staff failed to report serious incidents involving children in their care to the hotline. Incidents involving physical abuse between children were not reported timely.

Two children used one seat belt while being transported for an outing.

One staff member supervised 6 children in a van on 03/20/2022 when a physical altercation occurred.

Staff failed to report serious incidents involving children in care to the parents. Children have been involved in serious incidents requiring medical evaluations after and parents have not been informed within required time frames.

Staff failed to complete EBI documentation for serious incidents involving children in their care.

Medication logs reviewed did not include the reason medication was prescribed.

During the inspection; medication was observed accessible to the children in care and child in care pick up a pill off the floor.

During the inspection; a post discussion was not completed after restraint conducted on a child in care.

During the inspection; a post discussion was not completed after restraint conducted on a child in care.

One out of two youth files reviewed contained an incident report that did not match the emergency behavior intervention report to coincide with it.

One of the window blinds in bedroom three contained mold.