In His Hands Children Home

During the inspection, I observed one of four children?s medication records reflected the operation failed to administer the second dose of a medication prescribed for administration twice daily.

Fire and weather drill forms include the date, type, and length of evacuation, but no actual time that the drills took place.

Upon review of 2 employees files it was found that both employees completed the required TB test after their start date with the operation.

During the inspection, we observed 4 of 4 job descriptions that lacked documentation of position-required qualifications.

One child's medication record did not include the reason for prescribing the medication.

During the inspection, I observed 4 of 4 employee records reviewed lacked a statement signed by the employee acknowledging having read the operation Policies and Procedures.

A child was injured at school and taken to er the following day with a fracture. This should have been called into SWI

The fire extinguishers need to be serviced annually.

A child's medication record was missing pill counts for three days. Counts need to be entered within 2 hours after administration.

No assessments or evaluations were given to the worker when the child was discharged.

No services, accomplishments, or assessments were included in discharge paperwork

No background information or progress notes were given to the worker at discharged (or no documentation of it.

During the inspection, I observed two of four employee files showed TB test completed outside the 30 day window from date of employment or starting to volunteer at the operation.

During the walkthrough, I observed three over the counter medication logs lacked the time the medicine was administered.

During the walkthrough, I witnessed a child in care holding an applicator of over-the-counter medication she spilled on her blanket with no caregiver within auditory or visual range of the child.

During the inspection, I observed that three of the four employee files reviewed lacked documentation showing the date of employment for the individual.

The administrator's license expired on 12/14/23, and his renewal packet was submitted on 12/16/23, bringing the standard back into compliance on that date.

During the inspection, I observed that one of the four employee records reviewed lacked a copy of the employees' proof of educational level or equivalency.

During the inspection, I observed that one of the records reviewed did not have record of the Child's rights form in the file.

During the walkthrough, I observed cleaning chemicals and lice treatments stored in an unlocked cabinet in the kitchen, accessible to children. The operation relocated these chemicals to a secured location.

During the inspection, I observed that three of the four records reviewed did not have allergy information clearly identified in the file or on the outside of the record.

During the inspection, I observed that the administrator was not present and does maintain daily supervision and oversight of the operation.

During the walkthrough, I observed that the med log for the only child taking prescription medications did not record the name of the prescribing doctor nor the reason for the prescription.

During the inspection, the operation identified three individuals that ceased to be controlling persons on 10/17/23 that were not reported to licensing within the timeframe.

In review of the operation records, I observed that the administrator for the operation is also the administrator for another non-contiguous General Residential Operation in another region.

During the inspection, I observed that three of the fire extinguishers in the operation have not been inspected or serviced by a fire marshall or qualified entity within the past twelve months.

During the inspection, I observed that one of four employee files lacked proof of Tuberculosis screening completed within 30 days of initiating employment.

During the inspection, I observed three bedrooms that lacked curtains over the windows allowing shade for rest.

During the inspection, I observed that the first aid kits lacked scissors, adhesive tape, and thermometers.

In reviewing the policies and procedures, I observed that the EBI policies do not include a prohibition against retaliating against an individual for filing a complaint, grievance, or providing good-faith information regarding the misuse of emergency behavior intervention on behalf of another individual.

In reviewing the policies and procedures, I observed that the volunteer policies do not specify the training requirements for volunteers.

In reviewing the policies and procedures, I observed that the organizational chart does not label and specify the supervisory relationships between each tier of employee.

In reviewing the policies and procedures, I observed that the personnel policies do not contain policies specifying the training requirements for employees and caregivers.

During the inspection, I observed two of the four personnel records lacking current job descriptions.

In reviewing the policies and procedures, I observed the lack of a policy limiting access to the operation's files to persons within the operation authorized to access and see specific information in an electronic file.

In reviewing the policies and procedures, I observed the lack of a policy specifying which records must be in external paper files and those that can be stored electronically.

In reviewing the policies and procedures, I observed that the discipline policies do not detail how Trauma Informed Care is integrated into the care of the children.

In reviewing the policies and procedures, I observed the lack of a policy specifying plans for protection of paper or electronic records from destruction or loss.

In reviewing the policies and procedures, I observed that the admission policies do not specify whether the operation accepts emergency placements. The document states they will accept placement as needs arise for children.

In reviewing the policies and procedures, I observed a lack of policies specifying the Emergency Behavior Intervention training requirements, the curriculum that will be utilized, the amount and type of training required, training content, and how the training will be delivered.

During the inspection, I observed that the first aide kits reviewed contained several expired medications or supplies.

In reviewing the policies and procedures, I observed that the EBI policies state that only qualified caregivers can administer EBI, but the policy does not specify the training requirements or criteria by which a caregiver is deemed qualified.

In reviewing the policies and procedures, I observed that the EBI policies list a number of EBI procedures that do not match the EBI procedures listed on the application. The EBI description is not specific to the EBI system used.

In reviewing the policies and procedures, I observed a lack of policies specifying the posting of EBI practices where they can be viewed by children and adults or policies related to providing the clients with copies of the operation's emergency behavior intervention policies.

During the inspection, it was observed that four of the four personnel records reviewed lacked documentation of proof of education level for the employee.

In reviewing the policies and procedures, I observed that the policies do not specify the individuals outside of the operation with access to records.

In reviewing the documentation, I observed the lack of a policy addressing anti-virus protection systems.

In reviewing the policies and procedures, I observed that the policies do not specify the individuals within the operation with access to records.

In reviewing the policies and procedures, I observed that the lack of a policy addressing the requirements for routine back-up of data.

In reviewing the policies and procedures, I observed the frequency of reports to parents is not specified. The policy mentions regular reports but does not specify frequency.

In reviewing the policies and procedures, I observed that the policies do not include an orientation discussion with the child regarding the Emergency Behavior Intervention policies required in 748.113(5)(A)(i-ix).

In reviewing the policies and procedures, I observed that the EBI policies do not list specific techniques approved for use by caregivers and the general descriptions do not match what was identified on the application.

In reviewing the policies and procedures, I observed that the floor plan provided identifies rooms marked as bedrooms, but does not specify where caregivers and children will be sleeping respectively.

During the inspection, I observed that three of the four employee files reviewed lacked proof of TB test.

In reviewing the policies and procedures, I observed that the admission policies state they will admit without regard to sex; however, the operation is only applying to provide services for girls. The policies and procedures include parameters for Primary Medical Needs children, but the operation is not applying to provide such services. The admission policies do not state that they do not take Primary Medical Needs or emotional disturbance.

During the inspection, it was observed that a refrigerator in the kitchen lacked a thermometer.

In reviewing the policies and procedures, I observed that the background check policies do not specify the types of background checks applicable to the various positions employed by the facility.

In reviewing the policies and procedures, I observed that the EBI policies lack a prohibition against retaliation toward an individual for filing a complaint, presenting a grievance, or otherwise providing information about the misuse of emergency behavior interventions at the operation.

In reviewing the policies and procedures, I observed the lack of a policy pertaining computer security systems addressing confidentiality, password protection parameters, and network access.

In reviewing the policies and procedures, I observed that the visitation rights policies do not include policies for visitation between the children and friends. Dating is covered, but visitation with friends is absent.

During the walkthrough, I observed the window in the kitchen that would be used to ventilate in case of smoke not having a screen.

During the inspection, I observed that two of the four personnel files reviewed lacked drug testing results in accordance with the operation's policies.

During the inspection, I observed the protective surface fill to be at least two inches below the nine inch measuring mark on the equipment.