DART

Repeat violation established, special investigation : CCI Rule 400.4109 Program statement

Allegation 1: The facility is found in compliance as evidenced by interviews with staff and documents. Evidence does not support the allegations that staff are excessively on their phones for personal business or distracted by other electronic items such as iPod or television. Evidence suggests that at times this issue may have arisen in the past but not excessively per policy and documentation indicates the facility has taken action to ensure staff are aware of the policy and make changes in their behaviors. TECHNICAL ASSISTANCE: Technical assistance was offered regarding the examination of other communication devices such as radios. They reported trying this option but have youth take the radio and strike staff with it. Another option might be having each area of the facility with a microphone and a designated staff always listening so staff could speak for assistance. Allegation 2: The facility is found in noncompliance as evidenced by interviews with staff, and documents. Evidence supports the allegations that Former Staff 1 was not trained in HWC within the 90-day limit as outlined on the New Hire Training Registration Form. Although Former Staff 1 was scheduled for the training 3 times and failed to attend, it was the facility’s responsibility to ensure staff working with youth are trained in the approved behavior management techniques. During this investigation it was discovered that Staff 14 went 110 days before completing HWC training. Two of Five personnel records ...

Repeat violation established, special investigation : CCI Rule 400.4142 Health services; policies and procedures

The facility is found in noncompliance as evidenced by interviews with staff and documents reviewed. Evidence supports the allegation that there are eleven documented times youth did not receive the medication as ordered. There is no evidence of the 77 wrong medication being given during the time frame of Former Staff 1 working at the facility. TECHNICAL ASSISTANCE: Technical assistance was offered regarding the facility communicating the importance of medication passing being completed as ordered by the physician. They should also develop a system to ensure upcoming possible conflicts to the passing of medication are reviewed the week prior to medication being passed. This will allow the facility to develop plans to cope with any conflicts and still meet the requirements of passing medication. Technical assistance was offered regarding the facility developing a system of monitoring the amount of medication available on hand and when to have the prescription refilled or reordered from the physician. This should also be monitored by compliance. Technical assistance was offered regarding the facility completing forms, so communication is clear. The Incident Report of 10/3/25- 8:00am has “Corrective Measures taken” documented as “cvhfgjngdhm”. This is not a clear level of communication and leaves to much to question. Each form should be check for clear communication before being signed by staff. Technical assistance was offered regarding the facility completing incident reports ...

Repeat violation established, special investigation : CCI Rule 400.4158 Intervention standards and prohibitions

The facility is found in violation as per interviews conducted, Staff 1 and Youth A reported Staff 2 grabbed Youth A’s hair. Staff 2 reported Youth A did not have enough hair to grab, but Consultant interviewed Youth A face to face and confirmed that was untrue. TECHNICAL ASSISTANCE The facility should ensure staff are trained to swap out with other staff if they are being targeted by youth. In this situation, many offers were made to swap out and Staff 2 refused despite being targeted by Youth A repeatedly. Swapping out may have de- escalated the situation faster.

Violation established, special investigation : CCI Rule 400.4159 Youth restraint; pregnant youth; reduction,

The facility is found in violation based on interviews conducted. Staff 1 and Staff 2 were not consistent regarding the details of how they got Youth A from B-side to the cafeteria, Youth A could not remember how he got into the cafeteria, and no one else witnessed the situation. However, it is clear from both Staff 1 and Staff 2’s interviews, the way they got him there was not done appropriately. Whether they picked Youth A up and brought him into the cafeteria, or they held onto his arms and brought him in there while he was resistant, neither one is an appropriate or approved escort. Since Youth A was resistant, either method falls under the definition of a personal restraint, and neither method is an approved restraint technique. TECHNICAL ASSISTANCE: An email was sent to the facility on 3/14/25 explaining the difference between an escort and a restraint. This was also discussed with leadership during an on-site visit at the facility for their interim audit on 4/4/25.

Repeat violation established, special investigation : CCI Rule 400.4142 Health services; policies and procedures

The facility is found in non-compliance as evidence by interviews with staff, youth, document reviews, and video review of the medication process. Supervisor 1 admitted to providing the wrong medication to Youth A resulting in the violation. Other than providing the wrong medication, Supervisor 1 followed the facility’s policy/procedure for passing medication. This action could be accomplished by a check in process with the supervisor at the beginning of a shift. TECHNICAL ASSISTANCE: Technical Assistance was offered to the facility in the aspect of ensuring staff are of sound mind when beginning a shift especially staff involved in delicate activities such as passing medication. If a staff is struggling with personal issues, they should be relieved of a delicate assignment and to make sure the supervisor is aware of possible issues of deregulation for the staff.

Repeat violation established, special investigation : CCI Rule 400.4142 Health services; policies and procedures

The facility is found in non-compliance as Staff 1 confirmed she did not follow the facility’s medication procedure as she did not verify Youth A’s medications prior to giving him the medication. This caused Youth A to take medication that is not allowed to take due to the other medications he is on.

Violation established, special investigation : CCI Rule 400.4142 Health services; policies and procedures

The facility is found in non-compliance as per interviews conducted and documentation reviewed, Staff 1 did not follow the facility’s Medication Administration and Control Policy which says staff are to prepare one youth’s medication at a time. As a result, Youth A was provided the wrong medication on 8/9/24.

Repeat violation established, special investigation : CCI Rule 400.4126 Sufficiency of staff

This violation is established as per interviews conducted and documentation reviewed, Staff 2 did not provide supervision or follow Youth A’s safety plan as required.

Repeat violation established, special investigation : CCI Rule 400.4158 Intervention standards and prohibitions

Facility is found in non-compliance of this rule. Staff 1 and Youth A both reported Staff 2 swore directly at Youth A when he asked him a question. Staff 3 reported was not able to hear anything and Staff 4 reported she heard Staff 2 swear but was not sure who it was to, she did not believe it was Youth A but was not sure. Staff 2 admitting to swearing while working but it was not directed toward a youth.

Violation established, special investigation : CCI Rule 400.4109 Program statement

Facility is found in violation as Staff 1 did follow the incident reporting procedures about the concerns of Staff 2 swearing at Youth A. It is noted that staff are to report immediately to Program Manager and complete an incident report at the end of their shift when they have a concerning incident occur. Staff 1 admitted she did not follow the protocol.

Repeat violation established, special investigation : CCI Rule 400.4158 Intervention standards and prohibitions

Based upon interviews and written documentation there is evidence that supports Staff 1 did not follow the policy/procedure that required positive interventions with Youth A and Youth B. Staff 1 engaged in verbal abuse with Youth A and Youth B. Technical Assistance: Discussed with the facility the need to outline staff techniques within the residential treatment plan and not just the Individual Safety & Calming Plan. This will allow the referring worker to understand staff’s interventions with the youth.

Violation established, special investigation : CCI Rule 400.4158 Intervention standards and prohibitions

Based upon interviews and written documentation there is evidence that supports Staff 1 did not follow policy and/or rules when Staff 1 engaged in pulling Youth A during a reported escort of Youth A and pushing Youth A against the metal roll door in the cafeteria. Staff 1 also failed to follow the specific safety plan requirements during her interactions with Youth A.

Repeat violation established, special investigation : R 400.4126 Sufficiency of staff

The facility is found in non-compliance of sufficiency of staff. The staff did not follow the protocol of communicating when Youth A and Youth B were let into the living area of the unit to use the bathroom and bedroom. This led to Youth A and Youth B being left unsupervised on the living area side. Youth A has a safety plan in place that notes sexual behavioral concerns and staff should be aware of his location at all times. Technical Assistance: The safety plan policy for the facility should be reviewed and updated to indicate at what time staff should review and sign off on a youth’s safety plan during their shift.