Cumberland Hospital for Children and Adolescents

Non-compliance, DBHDS human rights inspection : 12VAC35-115-110. C. (10) The provider's duties. 10. Providers shall ensure that only staff who have been trained in the proper and safe use of seclusion ...

Upon review of CHRIS entry, A-20250006, the provider's investigation found: An authorized use of a restraint technique regarding Individual #1, which was conducted by Employee #1. • Employee #1 independently implemented a restraint which by the provider's policy, should have been implemented by two staff members when transitioning from a standing to a supine hold. Based on review of the investigator's finding, there is a preponderance of evidence to support the provider's findings of a regulatory violation.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

Upon review of CHRIS entry A-20250006: Entity # 1's disposition received revealed the following: Individual #1's account of the incident was consistent regarding the inappropriate restraint which resulted in injury to Individual #1. This was further corroborated by Entity #1's review of video footage and documentation from hospital. Employee #1 was overheard calling Individual #1 a "punk" during the incident. Based on Entity #'1 review, there is a preponderance of evidence to support a viiolation of this regulation.

Non-compliance, DBHDS unannounced inspection : 12VAC35-46-300. B. (3) The records of each employee shall include: 3. Professional references;

In review of all three personnel records, there was no documented evidence of written or oral notations of professional references.

Non-compliance, DBHDS unannounced inspection : 12VAC35-46-310. A. (1) Required initial training: 1. Within seven days following their begin date, each staff member responsible for supervision of children ...

In review of Employee #3's personnel record, there was no documented evidence of the following training, completed within seven days of hire date: basic orientation to the facility's behavior intervention policies, procedures, and techniques regarding less restrictive interventions, timeout, and physical restraint. Employee #3's hire date was July 14, 2025.

Non-compliance, DBHDS unannounced inspection : 12VAC35-46-440. B. All areas within buildings shall be lighted for safety and the lighting shall be sufficient for the activities being performed.

During the onsite inspection, the following areas will need lighting to be replaced for sufficiency: 1. Unit 8, the light bulb in bedroom #1 needs to be replaced to offer adequate lighting for the individual. 2. Unit 9, the light bulb in bedroom #2 needs to be replaced to offer adequate lighting for the individual.

Non-compliance, DBHDS unannounced inspection : 12VAC35-46-590. B. The interior and exterior of all buildings shall be safe, properly maintained, clean, and in good working order. This includes, but is not ...

During the onsite inspection for Unit 9, the following will need to be addressed: 1. In bedroom #1, there is a hole at the top of an outlet, located on the left side of the bedroom wall.

Non-compliance, DBHDS unannounced inspection : 12VAC35-46-1110. I. At least one evacuation drill (the simulation of the facility's emergency procedures) shall be conducted each month in each building ...

In review of the fire and evacuation drills for Unit 7, there is no documented evidence of a drill completed in the month of January 2025.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-260. A. (12) Providers, through their directors, shall: 12. Comply with requests by the SHRC, LHRC, or human rights advocate for information ...

Comply with requests by the SHRC, LHRC, or human rights advocate for information, policies, procedures, and written reports regarding compliance with this chapter. • During the Advocate's monitoring of the CHRIS reports A-20240009, the provider failed to provide evidence of a trained investigator for verification on January 3rd, 2025. Based on the Advocate’s review, there is a preponderance of evidence to support the violation.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

"Abuse" means any act or failure to act by an employee or other person responsible for the care of an individual in a facility or program operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, that was performed or was failed to be performed knowingly, recklessly, or intentionally, and that caused or might have caused physical or psychological harm, injury, or death to a person receiving care or treatment for mental illness, intellectual disability, or substance abuse. Examples of abuse include acts such as assault or battery. Upon the review of CHRIS entry, A-20240005, the provider’s investigation included the review of the provider’s policy and procedure which revealed the following: • Employee #1 failed to follow the provider’s policy and procedures: • Per the provider’s internal investigation report, Employee #1 admitted to grabbing Individual #1 by the arm to move them. • Employee #1 knowingly and recklessly assaulted Individual #1 using physical force, which meets the regulatory definition of abuse. Based on the provider’s investigative finding, there is a preponderance of evidence to support the provider’s substantiated finding of abuse.

Non-compliance, DBHDS unannounced inspection : 12VAC35-46-300. B. (5) The records of each employee shall include: 5. Annual performance evaluations;

In review of both Employee #1 and #2's personnel records, there is no documented evidence of a recent performance evaluation. 1. Employee #1's most recent performance evaluation in the personnel record was dated for year 2021. Employee #1's hire date was January, 2006. 2. Employee #2's most recent performance evaluation in the personnel record was dated for year 2022. Employee #2's hire date was November, 2020.

Non-compliance, DBHDS unannounced inspection : 12VAC35-46-480. F. Each child shall have a separate, clean, comfortable bed equipped with a clean mattress, clean pillow, clean blankets, clean bed linens ...

During the onsite inspection, the following was observed: Unit 8 1. Room 808-No sheet on the mattress 2. Room 810 and 811- No sheet and no pillow case Unit 9 1. Room 904 and 905- No sheet on the mattress

Non-compliance, DBHDS unannounced inspection : 12VAC35-46-500. A. (2) When bathrooms are not designated for individual use: 2. Bathtubs and showers shall provide visual privacy for bathing by use of ...

During the onsite inspection for Unit 8, bathroom #1 did not have a shower curtain to provide visual privacy.

Non-compliance, DBHDS unannounced inspection : 12VAC35-46-750. B. (3) Individualized service plans shall describe in measurable terms the: 3. Goals, objectives, and strategies established for the resident;

During the onsite inspection of the unit, Individual #3's mattress was observed on the floor in the bedroom. According to the provider and ISP, the individual has a history of epilepsy, receives brain scans daily, and has not had any episodes since placement. However, in review of the ISP, it does not specify placement of the mattress to be on the floor instead of the bed. The provider will need to identify other supportive options for preventive measures to address the history of the individual.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-110. C. (9a) - The provider's duties. 9. Providers shall comply with all applicable state and federal laws and regulations, certification and ...

Provider substantiated violation based on the following: • Upon review of CHRIS entry A-20230058, the provider's investigation determined a violation was substantiated. ◦ A camera review displayed the staff engage in an improper CPI escort/transport. The employee acting outside of the guidelines of CPI, during escort, violated the code of conduct, procedure on restrictive interventions and resident rights. Based on preponderance of evidence, Employee #1 failed to comply with provider's CPI standards.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

"Abuse" means any act or failure to act by an employee or other person responsible for the care of an individual in a facility or program operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, that was performed or was failed to be performed knowingly, recklessly, or intentionally, and that caused or might have caused physical or psychological harm, injury, or death to a person receiving care or treatment for mental illness, intellectual disability, or substance abuse. Provider substantiated abuse based on the following: • Upon review of CHRIS entry A-20230058, the provider's investigation determined abuse was substantiated. ◦ A camera review displayed the staff engage in an improper CPI escort/transport. The employee acting outside of the guidelines of CPI, during escort, violated the code of conduct, procedure on restrictive interventions and resident rights. Based on preponderance of evidence, Employee #1 failed to ensure the health and safety of Individual #1.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-260. A. (11) Providers, through their directors, shall: 11. Cooperate with the human rights advocate and the LHRC to investigate and correct ...

"Providers, through their directors shall cooperate with the human rights advocate and the LHRC to investigate and correct conditions or practices interfering with the free exercise of individuals' human rights and make sure that all employees cooperate with the human right advocate, the LHRC, and the SHRC in carrying out their duties under this chapter." • Upon review of Connect on 9/19/2023, • The provider was issued Corrective Action Plan (CAP), Inspection 250 on 8/28/2023. The provider was notified that the CAP response was due 9/19/2023. • The provider was issued a Connect email on 9/14/2023 reminding the provider that the CAP response was due in three business days. The email advised the provider that an extension may be granted by the department when requested prior to the due date. • On 9/22/2023, an email was sent to the provider notifying the provider of late CAP response and provider was instructed to enter CAP response by close of business 9/22/2023. • On 9/22/2023, the provider requested an extension. Extension request was denied as the provider had exceeded the time frame for requesting extension. • As of 9/26/2023, the provider has failed to provide the CAP response and failed to adhere to the established deadline.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-230. A. (3a) - Providers shall collect, maintain, and report the following information concerning abuse, neglect, and exploitation: 3. The ...

Upon review of the CHRIS entry A:20230030 and A:20230031, the provider failed to provide a written report of the results of the investigation within 10 working days from the date in which the investigation began. The investigative findings were due on 7/27/23. Findings were entered on 8/3/23.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

"Neglect" means failure by a person, program, or facility operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, responsible for providing services to do so, including nourishment, treatment, care, goods, or services necessary to the health, safety, or welfare of an individual receiving care or treatment for mental illness, intellectual disability, or substance abuse. Upon review of CHRIS entry A:20230030 and A:20230031, the provider's investigation which included eyewitness statements, individual interviews and review of camera footage which revealed: • Employee #1 did not complete observation round. • Individual #1 and Individual #2 were able to enter Individual #2's bedroom. Based on the provider's investigative finding, there is a preponderance of evidence to support the provider's substantiated finding of neglect.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-230. A. (3a) - Providers shall collect, maintain, and report the following information concerning abuse, neglect, and exploitation: 3. The ...

• Upon review of CHRIS entry A-20230029 on 7/26/2023, the provider was notified of the allegation on 7/10/2023. As of 7/26/2023, the provider has failed to provide the date the investigation began or a written report of the results of the investigation within 10 working days from the date in which the investigation began. • Employee #1 was notified via email on 7/25/2023 of the late reporting and requested to enter the written report by close of business 7/25/2023.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-70. A. (1c) - Each individual has a right to participate meaningfully in decisions regarding all aspects of services affecting him. This includes ...

Each individual has a right to participate meaningfully in decisions regarding all aspects of services affecting him. This includes the right to consent or not consent to receive or participate in services. The individual's services record shall include the signature or other indication of the individual's or his authorized representative's consent. Advocate substantiated violation based on the following: • Upon review of CHRIS entry C-20230005, the provider's investigation determined no violation. • On 8/8/2023, the provider was requested to provide verification of signed consent for medications. • The provider was unable to provide documented verification of signed consent for medications. Based on the preponderance of evidence, the provider failed ensure that Individual #1 and Individual #1's guardian the right to participate meaningfully in decisions regarding all aspects of services affecting Individual #1.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-175. C. (8) Upon receipt of a complaint, providers shall: 8. Report the director's decision and action plan within 10 working days to the ...

Upon receipt of a complaint, providers shall report the director's decision and action plan within 10 working days to the individual, authorized representative, if applicable, and human rights advocate. • Upon review of CHRIS entries C-20230001 - C- 20230004 on 7/10/2023, the provider failed to report the director's decision and action plan to human rights advocate within 10 working days.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-230. A. (3a) - Providers shall collect, maintain, and report the following information concerning abuse, neglect, and exploitation: 3. The ...

• Upon review of CHRIS entry A-20230023 on 7/10/2023, the provider was notified of the allegation on 6/12/2023. As of 7/10/2023, the provider has failed to provide the date the investigation began or a written report of the results of the investigation within 10 working days from the date in which the investigation began.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-230. A. (3a) - Providers shall collect, maintain, and report the following information concerning abuse, neglect, and exploitation: 3. The ...

• Upon review of CHRIS entry A-20230022 on 7/10/2023, the provider was notified of the allegation on 6/12/2023. As of 7/10/2023, the provider has failed to provide the date the investigation began or a written report of the results of the investigation within 10 working days from the date in which the investigation began.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-230. A. (3a) - Providers shall collect, maintain, and report the following information concerning abuse, neglect, and exploitation: 3. The ...

• Upon review of CHRIS entry A-20230020 on 7/10/2023, the provider was notified of the allegation on 6/4/2023. As of 7/10/2023, the provider has failed to provide the date the investigation began or a written report of the results of the investigation within 10 working days from the date in which the investigation began.

Non-compliance, DBHDS death or serious incident inspection : 12VAC35-46-1070. C. The provider shall notify the department within 24 hours of any serious illness or injury, any death of a resident, and all other ...

CHRIS Number: 20230010 Date/Time of Discover: 06/17/2023 7:24PM Enter Date/Time: 06/19/2023 12:57PM Reporting Delay: 17:33:00 Location Name: RTC Cumberland Unit 9

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

"Abuse" means any act or failure to act by an employee or other person responsible for the care of an individual in a facility or program operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, that was performed or was failed to be performed knowingly, recklessly, or intentionally, and that caused or might have caused physical or psychological harm, injury, or death to a person receiving care or treatment for mental illness, intellectual disability, or substance abuse. Provider substantiated abuse based on the following: • Upon review of CHRIS entry A-20230003, the provider's investigation determine Abuse was substantiated. ◦ Via camera review it was seen that Employee #1 secluded Individual #1 due to disruptive behavior and not due to being a risk to self or others. Based on preponderance of evidence, Employee #1 failed to ensure the health and safety of Individual #1.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

"Abuse" means any act or failure to act by an employee or other person responsible for the care of an individual in a facility or program operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, that was performed or was failed to be performed knowingly, recklessly, or intentionally, and that caused or might have caused physical or psychological harm, injury, or death to a person receiving care or treatment for mental illness, intellectual disability, or substance abuse. Provider substantiated abuse based on the following: • Upon review of CHRIS entry A-20230007, the provider's investigation determined physical and verbal abuse was substantiated. ◦ Via camera review, Employee #1 can be seen being verbally and physically aggressive with Individual #1. Based on preponderance of evidence, Employee #1 failed to ensure the health and safety of Individual #1.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

"Abuse" means any act or failure to act by an employee or other person responsible for the care of an individual in a facility or program operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, that was performed or was failed to be performed knowingly, recklessly, or intentionally, and that caused or might have caused physical or psychological harm, injury, or death to a person receiving care or treatment for mental illness, intellectual disability, or substance abuse. Provider substantiated abuse based on the following: • Upon review of CHRIS entry A-20220144, the provider's investigation determined verbal abuse was substantiated based on eyewitness statements. • Employee #1 used language that demeans, threatens, intimidates, or humiliates a person. ◦ Three staff were present and all three reported in statements that Employee #1 cursed at Individual #1 and threatened to "beat the resident's ass then press charges if the resident came [to a specific location]". • Based on preponderance of evidence, Employee #1 failed to ensure the health and safety of Individual #1.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

"Neglect" means failure by a person, program, or facility operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, responsible for providing services to do so, including nourishment, treatment, care, goods, or services necessary to the health, safety, or welfare of an individual receiving care or treatment for mental illness, intellectual disability, or substance abuse. • Upon review of CHRIS entries A-20220132 and A- 20220133, the provider's investigation determined neglect was found. Employee #1 failed to follow protocol and propped open the door separating the two sides of the unit, thus, creating a path for Individual #2 to get to Individual #1's room. Based on preponderance of evidence, Employee #1 failed to ensure the health and safety of Individual #1 and Individual #2.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

"Abuse" means any act or failure to act by an employee or other person responsible for the care of an individual in a facility or program operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, that was performed or was failed to be performed knowingly, recklessly, or intentionally, and that caused or might have caused physical or psychological harm, injury, or death to a person receiving care or treatment for mental illness, intellectual disability, or substance abuse. • Upon review of CHRIS entry A-20220127, the provider's investigation determined that verbal abuse and neglect was found. Based on preponderance of evidence, Employee #1 failed to ensure the health and safety of Individual #1.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

"Neglect" means failure by a person, program, or facility operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, responsible for providing services to do so, including nourishment, treatment, care, goods, or services necessary to the health, safety, or welfare of an individual receiving care or treatment for mental illness, intellectual disability, or substance abuse. • Upon review of CHRIS entry A-20220105, the provider's investigation determined Employee #1 was aware Individual #1 was on self-harm and elopement precautions and still took Individual #1 off the unit failing to follow the precautions per policy and neglect was found. Based on preponderance of evidence, Employee #1 failed to ensure the health and safety of Individual #1.