Moving Forward

Police responded to a GRO due to a serious incident that a child could have had criminal charges pressed against them.

While reviewing medication logs, it was discovered that the pill count on a child's medication log did not match the number of pills in the medication bottle.

Prescribed medication was not being administered to child as per health care professional orders.

One bedroom has a blind with broken slats and a hole in the door. Another bedroom has a hole in the closet and writing on the wall.

Service plan did not include a plan to address the three high-risk behaviors documented.

Four of four staff interviewed were not aware of the operation's policies and procedures regarding searches.

An initial service plan did not include all required signatures of the service planning team.

The operation was not following safety requirements listed in a child's service plan. The operation allowed a child in care to possess a sharp object and have access to social media.

The child's age, gender and date of admission was missing in eight of the eight serious incident reports reviewed.

Five children were administrator medications at the wrong time. Medications log was not documented correctly. Medications log shows that medications were administer at 8:00 PM. Medications and medications log were review at 7:38 PM.

Information gathered indicates that the operation failed to give a child in care the prescribed dosage of 1 ? tablets (75mg) of Seroquel on 09/21/2022. The medication log shows the child was administered 1 (50mg) tablet instead.

Two unauthorized debriefing forms were reviewed, and they did not document the trauma strategies that a child can use to avoid any future runaway behaviors.

One of the service plans reviewed was not signed by the child in care.

1 out of 5 children did not have their child rights sign in their file.

2 children records were review and both did not have dates entered on the unauthorized log summary for how long they were away from the operation.

The operation did not meet criteria for 2022 unauthorized absence evaluation. Compliance was met the operation provided documentation for 2023.

Child records reviewed did not contain any medication logs. One child does not have any medication logs for one medication. One child's total medication count on the medication log did not match the medication remaining in the container. Medication logs do not have the signatures of staff and only have initials.

The operation did not receive written consent from the child's conservator before allowing a physician to change the child's psychotropic medication.

The first aid kit in the vehicle used for transporting children in care does not contain tape, scissors, thermometer, tweezers or disposable loves.

Caregiver did not follow the operation's policies that states staff cannot sleep during their shift.

A caregiver did not exercise prudent judgement when they provided a vape pen to two children in care.

Caregiver did not follow the service plans of children in care that require 24 hours supervision and 15 minute bed checks during sleeping hours.

Children in care had possession of a vape pen and used the vape while residing at the operation.

A child in care was able to access and ingest a staff member's prescription medication.

A child had a safety plan in place due to behaviors, that required being checked on every 15 minutes. The caregivers were not checking on the children every 15 minutes.

The administrator was not present at the operation during their scheduled work hours and arrived during the inspection. This standard is being re-cited due to the administrator not following up on this deficiency from a previous inspection.

One staff record reviewed did not contain documentation of their TB test.

One staff record reviewed did not contain a signed, notarized Affidavit for Applicants for Employment.

Two personnel files reviewed did not have documentation of the staff meeting the minimum job qualifications.

The administrator was not present during their scheduled work time and arrived during the inspection.

Of the ten serious incident reports reveiwed, four reports did not have the operation's address & phone number, and one incident did not have the name of the adult staff that was involved in the incident.

Two staff records reviewed did not have signed statements for reporting abuse and neglect.

A child was left unsupervised while away from the operation despite their service plan stating they are to be supervised at all times.

A caregiver did not follow the operation's policies on supervision when they left two children unattended while away from the operation.

While away from the operation, two children were left unattended with no way to contact the staff when the caregiver left to charge their cellphone that had died.

A child's service plan does not state specific supervision requirements based on the child's age, behaviors, and level of care.

A caregiver left two children unsupervised while away from the operation.