Chrysalis Therapeutic Boarding School

Deficiency cited, renewal inspection

The surveyor’s review of 5 current participant charts on July 9th , 2025.

Deficiency cited, renewal inspection

1)Participant #1, and Participant #4’s record did not have signed documentation of a completed ICPC prior to admit date. Participant #1 admit date was 6/25/25 and has no documentation of ICPC being completed. Participant #4 admit date was 3/31/25 and did not receive completed ICPC back till 4/14/25.

Deficiency cited, renewal inspection

The surveyor’s review of 2 discharged participant charts on July 9th, 2025.

Deficiency cited, renewal inspection

1)Discharged participant #1’s discharge summary at discharge did not include the following: -Contact information of the persons that conducted evaluations. -Medical, dental, and psychiatric care received during

Deficiency cited, renewal inspection

1) Program records did not contain written documentation of first aid kits being inventoried on a quarterly basis.

Deficiency cited, renewal inspection

The surveyor’s on-site review of the program on July 9th, 2025.

Deficiency cited, renewal inspection

1) The program did not properly store cleaning materials, flammable liquids, detergents, aerosol cans and other poisonous and toxic materials. These chemicals must be kept in a place inaccessible to program participants.

Deficiency cited, renewal inspection

The surveyor’s review of program records on July 9th, 2025.

Deficiency cited, renewal inspection

1) Program records did not contain a written quality management report written within the last year.

Deficiency cited, renewal inspection

The surveyor’s review of 12 staff charts on July 9th, 2025.

Deficiency cited, renewal inspection

1) Staff #8, #9, #11, and #12’s record did not contain written documentation the staff completed an orientation in the following: - Emergency medical procedures. - Program participants rights and grievances.

Deficiency cited, renewal inspection

1) Staff #3, #4, and #5’s record did not contain up to date CPR and first aid certificates.

Deficiency cited, renewal inspection

1) Staff #2 and #3’s record did not contain written documentation of 20 hours of on-going training in the last year.

Deficiency cited, renewal inspection

1) Cold storage of potentially hazardous food must be at 41 degrees Fahrenheit or below. The fridge with food in the back hallway was 54 degrees Fahrenheit.

Deficiency cited, renewal inspection

The surveyor’s review of 8 current participant charts on July 30, 2024.

Deficiency cited, renewal inspection

1) Participant #1, #2, #4, #5, #6, and #8 did not have an orientation completed within 24 hours of admission. • P#1 had admission date of 7/10/24 with orientation completed on 7/15/24; • P#2 had admission date of 5/24/24 with orientation completed on 5/30/24; • P#4 had admission date of 9/21/23 with orientation completed on 9/25/23; • P#5 had admission date of 6/20/24 with orientation completed on 6/23/24; • P#6 had admission date of 12/1/23 with orientation completed on 12/4/23;and • P#8 had admission date of 6/6/24 with orientation completed on 6/26/24. THE INTENT OF THIS RULE HAS NOT BEEN MET AS EVIDENCED PROGRAMS: DISCHARGE BY: The surveyor’s review of 4 discharge summaries on July 30, 2024.

Deficiency cited, renewal inspection

1) The program discharge summaries for DC1-DC4 are missing the following required information: • The medical, dental and psychiatric care that was provided during placement; • Current medications, dosage and prescriber of current medications; • The participants reaction to discharge; • The participants progress in services provided; • Contact information for person completing the summary; and • A copy of the discharge summary was provided to the parent or guardian at discharge.

Deficiency cited, renewal inspection

1) Participant #1, #2,and #3’s initial case plans were not completed within 7 days of admission. • P#1 had an admission date of 7/10/24 with the initial case plan completed on 7/20/24; • P#2 had an admission date of 5/24/24 with the initial case plan completed on 5/23/24;and • P#3 had an admission date of 9/11/24 with the initial case plan completed on 9/7/24.

Deficiency cited, renewal inspection

1) Participants #1 - #8’s initial case plans and reviews or updates are missing the following information: • Measurable goals with corresponding time frames; • Responsibilities of the parent and program; and • Discharge plans with an estimated discharge date.

Deficiency cited, renewal inspection

2) Participants #1 - #8’s initial case plans and reviews or updates are missing documentation that the parent or guardian was involved in the update or review.

Deficiency cited, renewal inspection

3) Participants #1 - #8’s initial case plans and reviews or updates are missing documentation that the parent or guardian received a copy of the plan or reviews.

Deficiency cited, renewal inspection

The surveyor’s review of 15 staff charts on July 30, 2024.

Deficiency cited, renewal inspection

1) Staff #2, #3, #4, #5, #6, #8, #9 records did not contain a current periodic performance evaluation. 2) -Staff #5- missing proof of GED/Diploma and no acceptance/review/training of Policies Procedure Manual. (hire date was Feb 24). 3) -Staff #8-Missing recent employee evaluation. 4) -Staff #9-Missing proof of valid driver’s license and no acceptance/review/training of Policies Procedure Manual. (hire date was May 24).

Deficiency cited, renewal inspection

1)Staff #1 , #2, #3, #4, #6, #7, #8, #10, #11, #12, #13, #14 and #15’s staff records did not have documentation of completing suicide prevention and 20 hours ongoing training.

Deficiency cited, renewal inspection

1) Participant #1-#8’s records did not contain documentation of searches conducted on the participants belongings at intake.

Deficiency cited, complaint inspection

The surveyor’s review of participant complaints and program documentation on 6/3/24.

Deficiency cited, renewal inspection

The surveyor’s review of eight participants records out of twenty-five on June 7, 2023.

Deficiency cited, renewal inspection

1) Participant #4’s records did not include written documentation that an orientation was at the time of admission. Participant #4’s admission date was 3/6/23 with no documentation of orientation. 2) Participant #1 and #8’s record had documentation that an orientation was completed but was not done on the day of admission. Participant #1’s admission date of 2/28/23 with orientation completed on 3/13/23 and Participant #8 admission date of 5/15/23 with orientation completed on 5/23/23.

Deficiency cited, renewal inspection

The surveyor’s review of two discharged participant record on June 7, 2023.

Deficiency cited, renewal inspection

1) Discharge participant #1 and #2’s discharge summaries did not include documentation that the discharge summaries were completed on the day of discharge and a copy provided to the parent or guardian. Participant #1 had a discharge date of 3/24/23 and summary completed on 4/7/23 and Participant #2 had a discharge date of 1/3/23 and summary completed on 1/13/23.

Deficiency cited, renewal inspection

The surveyor’s review of eight participants records out of twenty-five participants on June 7, 2023.

Deficiency cited, renewal inspection

1) Participant #4 and #8’s initial case plans were not completed within 7 days from admission. Participant #4 admission date was 3/6/23 and the initial case plan completed on 4/19/23. Participant #8 admission date of 5/15/23 and the initial case plan completed on 5/24/23.

Deficiency cited, renewal inspection

The surveyor’s onsite review on June 7, 2023.

Deficiency cited, renewal inspection

1) The program is currently not providing awake night staff in each building that is housing participants. At the horse house there are currently two participants that are living in a separate building that is not connected to the main home and do not have an awake night staff present. THE INTENT OF THIS RULE HAS NOT BEEN MET AS EVIDENCED PROGRAMS: STAFF TRAINING BY: The surveyor’s staff record review of ten staff out of forty staff records on June 7, 2023.

Deficiency cited, renewal inspection

1) Staff #3, #4, #5, #6, #7 and #8’s training record did not include documentation of 20 hours of ongoing training provided to staff annually. The program did not have documentation of any ongoing training being provided.

Deficiency cited, renewal inspection

The surveyor’s review of ten participants records out of forty participants on June 8, 2022.

Deficiency cited, renewal inspection

1) Participant #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10’s records did not include written documentation that an orientation was provided to participants on the program’s; • Search policies and procedure; and • Emergency evacuation procedures including designated escape routes.

Deficiency cited, renewal inspection

1) Discharge participant #1 and #2’s discharge summaries did not include documentation of the following requirements: • The participants reaction to discharge whether planed or not; • medical, dental care received during placement; • current list of medications with dosages and prescriber; • follow up health care required; and • an up-to-date inventory sent at the time of discharge to parent or guardian.

Deficiency cited, renewal inspection

The surveyor’s participant record review of ten participants records out of forty participants on June 8, 2022.

Deficiency cited, renewal inspection

1) Participant #1, #2, #3, #4, #5, #6, #7, #8 , #9 and #10’s case plans did not include a discharge plan with an estimated discharge date on initial case plans or subsequent reviews and updates. .

Deficiency cited, renewal inspection

The surveyor’s onsite inspection on June 8, 2022.

Deficiency cited, renewal inspection

1) In Lake house the two upstairs bedrooms had clothing, food, garbage and personal items of the participants covering the floor. 2) There is a 2 by 2-inch hole next to the light switch in the upstairs of lake house. 3) In bathroom #3 in Lake House the exhaust vent was unoperational. 4) In the back area of Lake house there are two extension cords that are plugged in outside next to the exit door and off the deck by BBQ into a crawl space under the home. 5) In the school in the mudroom the left window is missing the release lever to unlock the window.

Deficiency cited, renewal inspection

The surveyor’s staff records review of twelve staff records out of fifty staff on June 8,2022.

Deficiency cited, renewal inspection

1) Participant #1,#2, #3, #4, #5, #6 , #7’, #8 #9, and 10’s records for searches conducted at the time of admission did not include the following documentation: • reasons for the search; • the results of the search; and • who conducted the search.

Deficiency cited, follow up inspection

The surveyor’s review of five participants records on October 21, 2020.

Deficiency cited, follow up inspection

1) Participant #1, #2, #3, #4, and #5’s case plans did not have corresponding time frames and measurable goals and objectives.

Deficiency cited, follow up inspection

1) Participant #1, and #2’s initial case plan was not completed within 7 days of admission. Participant #1 with an admit date of 9/29/20 with the initial case plan developed on 10/19/20; and Participant #2 with an admit date of 9/3/20 with the initial case plan developed on 9/21/20.

Deficiency cited, follow up inspection

1) The program does not maintain the minimum program participant to awake-staff ratios of eight program participants to one staff for the following shifts: a) Horse House: Sunday- No staff scheduled 7am to 8am. Tuesday- No staff scheduled from 9:45pm to 10pm Wednesday- No staff scheduled from 9:45pm to 10pm Thursday- No staff scheduled from 9pm to 10pm Friday- No staff scheduled from 9:30pm to 10pm Saturday- No staff scheduled from 9:30pm to 10pm

Deficiency cited, follow up inspection

1) Participant #3, and Participant #4’S record did not contain documentation of a physical examination within a year prior to placement or within 30 days after admission. REPEAT DEFICIENCY

Deficiency cited, follow up inspection

1) Participant #4’s and Participant #5’s record did not contain documentation of a dental examination within a year prior to placement or within 90 days after admission.

Deficiency cited, follow up inspection

1) Participant #4 and #5’s records did not contain documentation of a vision examination within a year prior to placement or within 90 days after admission.

Deficiency cited, renewal inspection

The surveyor’s review of eight participant records on May 7, 2020.

Deficiency cited, renewal inspection

1) Participant #1, #2, #3, #4, #5, #6, #7 and #8’s records did not include written documentation that an orientation was provided to participants by the program within 24 hours on the following requirements: • Behavioral expectations, • Information on the privilege system; • Discipline policy; • Program rules; and • information on the program’s search polices and procedure

Deficiency cited, renewal inspection

1) Discharge participant #1 and #2’s written discharge summaries were not completed at the time of discharge as required. Discharge date for P#1 was 1/17/20 and summary was completed on 1/20/20 and for P#2 was 1/20/20 and the summary was completed on 2/10/20.

Deficiency cited, renewal inspection

1) Participant #6’s case plan dated 2/20/20, Participant #7’s case plan dated 3/8/20 and Participant #8’s case plan dated 4/20/20 did not include a discharge plan or an estimated discharge date.

Deficiency cited, renewal inspection

1) Participant #1, #2, #3 ,#4, #5, #6, #7 and #8’s case plans did not include written documentation that the participant as well as the parent/legal guardian participated in the development and updating of the case plan.

Deficiency cited, renewal inspection

1) Participant #1, #2, #3, #4, #5, #6, #7 and #8’s case plans did not include written documentation that a copy of the signed case plan was provided to the parent/legal guardian.

Deficiency cited, renewal inspection

1) A signed statement documenting the program reviewed the grievance policy with program participants and parent/guardian did not include the staff member’s signature of who completed the review for Participant’s #1, #2, #3, #4, #5, #6, #7 and #8’s record.

Deficiency cited, renewal inspection

1) Lake House: - Bathroom #1- had a corner piece of trim missing; - Bathroom #2 Upstairs: had a heavy dust build up on the exhaust fan and the wall next to the fan. 2) Cottage House: - Bedroom #2- had 4”X4” hole in the closet door; has a 2”X2” inch piece of carpet missing next to the closet; - Bathroom #1-the board on the bottom left of the vanity is breaking apart at the base; and - Kitchen next to the stove a 3-inch piece of the countertop trim is peeling off. 3) Horse House: - Both the Kitchen stove upstairs and downstairs had a heavy build up of grease on the burner covers; by the basement door threshold strip is lose and missing 3 screws; the bathroom by the laundry room had a black substance present on the calking; and by the basement exit of connected room had the linoleum splitting and separating.

Deficiency cited, renewal inspection

1) In the horse house in the area of the hot water heaters the program had stored 4 wooden ladders as well as two wooden doors.

Deficiency cited, renewal inspection

1) The following individual orientation trainings required were not documented for the following staff: • Mandatory Child Abuse reporting laws: S# 1, S#2, S#4, and S#8; • Report writing and development of logs; S# 1, S#2, S#4, and S#8; • Time-out policy and procedures: S# 1, S#2, S#4 and S#8; • Search policy and procedures: S# 1, S#2, S#4 and S#8; and • Program participants rights as outlined in 37.99.125: S# 1, S#2, S#4 and S#8;

Deficiency cited, renewal inspection

1) Participant #1,#2,#3, and Participant #4’S record did not contain documentation of a physical examination within a year prior to placement or within 30 days after admission.

Deficiency cited, renewal inspection

(1) Participant #3 and #6’s records did not contain documentation of a vision examination within a year prior to placement or within 90 days after admission.

Deficiency cited, renewal inspection

1) Participant #1, #2, #3, #4, #5, #6’s, 7’s and 8’s records for searches conducted at the time of admission did not include the following documentation: • reasons for the search; • the results of the search; and • who conducted the search.