Eagle Village Ashmun-Sherk

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

The facility is found in noncompliance as per staff and youth interviews and video review, staff were not actively supervising Youth A and Youth C. Staff were observed on their phones. Staff 1 and Staff 2 were aware of Youth C’s BCP and did not follow the plan.

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

The facility is found in non-compliance as per staff and youth interviews and lack of weekly documented therapy notes, Youth A was not provided the opportunity for weekly therapy.

Violation established, special investigation : CCI Rule 400.4112 Criminal history check, subject to requirements; staff qualifications

The facility is found in noncompliance as per interviews it was determined Staff 1 did not have the ability to perform the functions of the position, however, it should be noted the facility did terminate Staff 1’s employment shortly after becoming aware of concerns regarding Staff 1. Per interviews with staff, concerns with boundaries began occurring in September/October 2024 with several staff having concerns of red flags. Administrator 1 was informed in October 2024 Staff 1 had been in the basement with Youth A and a staff felt something was not right. Immediately after being informed, Administrator 1 placed Staff 1 on administrative leave while an internal investigation was completed however Staff 1 never returned Administrator 1’s phone calls to come into the facility regarding the internal investigation and the facility terminated Staff 1. Video footage during the time Staff 1 was alone in the basement with Youth A was reviewed and found Staff 1 allowed Youth A to use his cellphone and no other concerns. The concerns of Staff 1 having inappropriate relations with Youth A arose upon a note Youth A wrote to a peer being found on 4/28/2025 indicating inappropriate relations had occurred at which time Staff 1 was no longer employed at the facility. Per Youth A’s interview, Youth A reported having sexual interactions with Staff 1 as well as additional concerns of Staff 1 having boundary concerns with Youth A and Youth D as Staff 1 reportedly reached out to Youth D after ...

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

The facility is found in noncompliance as per youth and staff interviews as well as documentation two youth did not receive their prescribed medication. There were no findings of youth being over-medicated or youth getting medications more than once a day.

Violation established, special investigation : CCI Rule 400.4132 Grievance procedures

The agency is found in noncompliance as per Youth B and Clinical Services Manager interviews, Youth B completed a grievance form, gave the grievance form to Clinical Services Manager and Clinical Services Manager gave the grievance form to Supervisor 3. The grievance form cannot be located by the facility and was not logged as ever being completed and turned in by Youth B.

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

The facility is found in noncompliance as per Staff 3’s interview she did not lock her purse containing her vape pen in her vehicle. Per Staff 3’s interview Youth A, Youth B, and Youth C took a hit off Staff 3’s nicotine vape pen in front of Staff 3 and Staff 3 did not tell any supervisor/administrator of the incident or document the incident. 8

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

The facility is found in noncompliance as per staff and youth interviews as well as reviewing the incident reports, Staff 4 did not allow Youth A back into the house and directed Staff 1 and Staff 3 to have Youth A take the full five minutes outside on the porch. The facility is found in noncompliance as per staff and youth 6 interviews Staff 4 verbally engaged in matching Youth A’s escalation and knocked over Youth A’s laundry basket in frustration with Youth A. TECHNICAL ASSISTANCE: Technical assistance was discussed finding a safe space for Youth A inside the home during the colder months. It was also discussed having staff understand how a decision to not allow a youth inside because a full five-minute break did not occur, could have led to serious safety concerns for Youth A.

Violation established, special investigation : CCI Rule 400.4150 Incident reporting

The agency is found in noncompliance as they did not notify law enforcement, the parent/legal guardian, the referring agency or the licensing authority.

Violation established, special investigation : CCI Rule 400.4163 Health status assessment; notification; debriefing; reporting.

The facility is found in noncompliance as incident report 177380233 was not approved in MiSACWIS within 72 hours of the incident and there were no incident reports entered in MiSACWIS or completed on the form prescribed by the department for Youth A being restrained by Staff 3 or Youth B being restrained by Staff 5 on 3/15/2024.

Violation established, special investigation : CCI Rule 400.4127 Staff to resident ratio

The facility is found in noncompliance as Staff 3, Staff 5, and Staff 6 were scheduled to be working in Sherk house on March 15, 2024, with six youth and Staff 3 and Staff 5 left to respond for additional staff assistance call leaving Staff 6 with six youth. The 8 facilities staff ratio policy states the ratio during awake hours is one to three staff/resident.

Repeat violation established, special investigation : R 400.4160 Emergency Restraint

The facility is found in non-compliance as Staff 2 placed Youth A in a restraint for throwing a lotion bottle at Youth C, then running toward the door and attempting to push past Staff 2. The physical restraint was not warranted.

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

The facility is found in non-compliance as the youth was sent on a home pass without the prescribed amount of Vyvanse to cover the length of time the youth was supposed to be on the home pass. The facility did not follow internal policy and procedure to ensure the amount of medication needed for the home visit was available, the appropriate amount of medication was not packed to cover days the youth would be off campus, transportation coordinator was not aware there were not enough medications, and the transportation coordinator did not review and count the medications the with individuals responsible for medication administration during the home visit. TECHNICAL ASSISTANCE: It was recommended to the agency a protocol be put into place that if medications need refills that are unable to be obtained prior to a home pass due to the length of time the youth will be gone, arrangements will be made to get medications to the individual responsible for medication administration while the youth is on the home pass prior to running out. Medication Administrator Record’s should be checked regularly to ensure the form is filled out completely and notes are documented as the form direction states.