Perfect Start Homes INC

During the inspection, the thermometer in the freezer was observed to be missing.

The operation's suicide screening tool was created by the operation and cannot be verified to be an approved tool that is supported by evidence-based research.

In a review of the provided operation schedule, it was found that the Administrator was out on leave for an extended period of time. There was no designated back up provider.

In a review of Serious Incident Reports, it was found that one child witnessed a sexual act conducted by a child of an opposite gender.

It was found that one staff member does not meet the qualifications of a PLSP with the professional or educational qualifications. This staff member was completing the assessments and the plans for the children.

In a review of the serious incident report, it was missing the following components: 3: The name, age, gender, and date of admission of the child or children involved. 4: The name of all adults involved and their role in relation to the child(ren) 7: The circumstances surrounding the incident. 10: The resolution of the incident

Two child records reviewed were missing required information on both initial service plans.

In a review of children's medication logs, the following issues were noted: - Two children are noted to have missed the AM dose on 12/7 for multiple medications. - One child received a half dose on 11/28 - One child received a double dose in the AM on 11/22 - One child missed a dose on 11/29 - One child received a double dose on 11/28 and missed a dose on 11/29.

A staff member was observed with a vape at the dining table upon arrival for the inspection.

The Case Manager was signing off as the treatment director. They do not possess the qualifications of a treatment director for children with ID, ASD, or ED.

Two child records reviewed didn't have the reason the child was taken the medication listed on the medication log.

In a review of the two service plans, neither child was provided a copy, nor was the plan signed by the children. There was also no justification documented for not sharing the plan with the child.

Two child records reviewed didn't have the daily count listed on the medication log.

In two child records, the PLSP did not sign and date the assessments.

The policies reflected that the operation will not accept emergency placements which needs to be corrected, the operation will be accepting emergency placements, but the operation isn't an emergency shelter.

The policy is missing the preservice training requirements for caregivers as well as EBI components

The operation policies is missing Medical contraindications and religious beliefs.

The operation's policy does not address screening and selection procedures.

The operation's policies has conflicting information regarding the use of restraints as well as missing information on the specific description of the interventions that are permitted.

The outside fence is in need of repair with protruding nails.

The required components were missing regarding orientation with a child in regards to EBI requirements. Missing (A)(i)-(ix)

The operation's policies are missing the required components of standards 2-5.

The policy does not state the program rules and expectations that apply to the children.

The requqired statement that the majority of the voting members of the governing body must consist of persons who do not have a conflict of interest that would potentially interfere with objective decision making was missing in the policies.

The required information wasn't included in the operation's policies.

The required statement of employee may not delegate the responsibility to make a report wasn't included in the policies.

The operation's policy reflected they will be accepting girls, however the operation will be licensed to care for boys only, which wasn't correct on the operation's policies.

The operation was missing the components in the policy--(2)-(5).