AT LAST!, Inc.

Operation did not submit EBI information for quarter 3.

Two of three staff CPR certificates reviewed did not include the trainer's qualifications. The certificates also did not include the length of the training.

Three staff files were reviewed, and one staff file did not include TB test results.

One staff's file contained reference checks that did not include all required information about the reference.

During the inspection three fire extinguishers were observed to have expired in April 2024.

The medication cabinet was unlocked during the inspection. Non-prescription ointments were stored in an unlocked cabinet that was accessible to children.

Operation runaway log did not have information for the gender date of admiission or if law enfrocement was contacted.

Three of the three child files that were reviewed did not document the date the preliminary service plan was completed.

Child admission assessment did not have immunization record and other important information.

Van used to transport children did not have current liability insurance.

A child in care was self administering an inhaler and there was no documentation.

The operations did not have all documentation completed documentation was contractidcing on dates and information.

The operation allowed a caregiver to have contact with the children in their admission assessment program prior to the caregiver having a TB screening completed.

The operation had designated a volunteer to be reponsible when the administrator was not at the facility.

Two lighters were located in a drawer in the common living area.

At Last! does not have written relocation plan.

Bunkbeds in all bedrooms were missing the ladder.

AtLast! policy does not document the information needed when conducting a monthly smoke alarm detecter.

Operation policy did not specified who has acess to the records.

At Last! does not have policies and procedures regarding volunteers contracting with other organizations.

At Last! safety polices does not include these additional safety provisions

The policy does not address all areas of the Addressing Suicide Attempts.

The operation admission policy did not specify the gender they will provide services for.

4 out 4 Children's bedroom did not have a designated space to store clothing for their belonging.

Grass at the facility was overgrown.

At Last! medication policies does not document requirements regarding administering epinephrine auto-injectors

The operation?s policy does not indicate which suicide prevention training curriculum staff/volunteers/non-employees will be required to take.

The Suicide Prevention Intervention and Postvention Policy submitted by the operation does not indicate when Suicide Risk Screenings will be completed for specified ages of the children admitted to the operation.

Bunkbeds in all bedrooms were missing the ladder.

The operation does not indicate the ages of the children they will screen. The operations states they will screen quarterly, however, the standards indicate that a child should be screened every 90 days.

The operation's Suicide Prevention, Intervention, and Postvention Policy does not include a detailed plan for Postvention plans and protocol.

The operation?s policy does not indicate how they will promote suicide prevention training for non-employees, as appropriate.

At Last! policies and procedures does not document that a personnel record will be kept for volunteers for the operations.

At Last! psychotropic medication policies does not include the following information: a description of any accompanying discomforts and risks, including those which could result from long-term use of the medication, and possible side effects, including side effects that are known to frequently occur in persons, side effects to which the child may be predisposed, and the nature and possible occurrence of irreversible symptoms; a statement of whether the medication is habituating in nature; alternative interventions to the use of psychotropic medication that have been attempted and that have been unsuccessful; other alternative treatments or procedures to the use of the psychotropic medication; risks and benefits of the alternative treatments or procedures; and risks and benefits of not receiving or undergoing a treatment or procedure.

At Last! safety policies does not document what documentation is required for gas inspections.

Childrens bedrooms did have appropritate window covers to provide privacy.

At Last! safety policies does not document who must conduct a gas inspection for the operation.

At Last! discipline policies does not document that making a child do physical exercise as discipline is prohibited.

At Last! safety policies does not document when the operation needs to be inspected for gas leaks.