Girlstown

Repeat violation established, special investigation : CCI Rule 400.4150 Incident reporting

The agency was found to be in noncompliance based on staff interviews and a review of documentation. There was an AWOL on 5/18/26 and on 5/26/26. Policy requires the agency to immediately notify the licensing authority when a youth is absent without legal permission. The agency's policy also requires an incident report to be completed immediately following an incident; however, the incident report was not completed until 6/1/26.

Repeat violation established, special investigation : CCI Rule 400.4150 Incident reporting

There is a rule violation established regarding this allegation. There is no record of reporting the AWOL incidents on 12/12/2025, 12/13/2025, 12/19/2025, 12/27/2025, 12/28/2025, and 1/7/2026 to the Division of Child Welfare Licensing. Technical Assistance: The facility AWOL Policy and Procedure is to have added language detailing that the Licensing Authority/Division of Child Welfare Licensing needs to be notified of AWOL incidents immediately.

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

The facility is found in noncompliance as evidenced by interviews with staff, youth, and documents. Evidence indicates staff did not follow the procedure of documenting when medication was refused on the MARS form, thus not following the Girlstown Medication Pass Policy and Procedure MARS. This procedure states that staff are to document their initials on the medication time box, circle their initials, write the reason the dose was not given on the back of the medication sheet and the staff’s signature was not present. The Medication Administration Record (MAR) also showed staff failed to document Youth A taking the medication on 11/18/25, 11/19/25, 11/20/25, and 11/21/25. TECHNICAL ASSISTANCE: Technical assistance was offered regarding the facility clearly communicating with the referral source when determining the level of care needed to ensure the youth is being provided the appropriate level of medical care. If the youth has been determined to have the ability to properly manage their medication, then the youth needs to demonstrate this ability to the facility. Allowing the youth a chance to demonstrate this level of care should involve close monitoring by the staff but also verifying is a rule that should be put into place when dealing with such a significant issue as medication monitoring. This communication should be documented in the youth’s file as it occurs and clearly documented by both the facility and referral source. Technical assistance was offered regarding ...

Violation established, special investigation : CCI Rule 400.4162 Seclusion within secure and nonsecure facilities; seclusion plan;

A rule violation is established regarding this allegation. It was consistently reported by youth and staff youth have been in the stairwell and not let back into the hallway right away until they were called. Technical Assistance: The facility should revise their behavioral management policy to include language defining and prohibiting seclusion.

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

A rule violation is established regarding this allegation. Per interviews with staff, Supervisor, Program Manager and Youth A, it was not the facility’s intention or decision to send Youth A to the hospital for evaluation. It was at the recommendation of EMS and the police who were at the scene due to being called for an allegation of Youth A assaulting Supervisor. The facility’s procedure states following an attempt of suicide, it is required youth be sent to or taken to the hospital for crisis-screening which was reportedly not the intention of the facility. Several interviews stated Youth A had made previous self-harm or suicidal comments and or/gestures in the past including the documented incident on 7/22/25. Technical Assistance: The facility should revise their Suicide Precautions Policy to include proper documentation of self-harm ideations, comments, and follow-up. Consultation: It is recommended that an updated training be created for all staff regarding self-harm and suicidal ideation and procedure. This training should include taking any and all gestures, comments, and attempts of self-harm or suicide seriously whether the manner of attempt is considered dangerous or effective or not. It is recommended that a licensed clinician make risk determinations for self-harm and suicide. The facility’s Treatment Team does not presently include any licensed or limited licensed clinicians. 14

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

The agency is found in noncompliance in dispensing Youth A’s Latuda and Lithium as prescribed based on the remaining Latuda and Lithium pills in the pill bottles and the blank spots on Youth A’s 07/2025 MAR. CONSULTATION It is recommended to utilize a key for the MAR when medication is not dispensed as prescribed (e.g. capital letter R for refusal, circle for out of medication, T for truant) in addition to an incident report. It is recommended for Girlstown’s Medication Procedure and Administration Guidelines policy and procedure to identify the person(s) that are responsible for verifying medication is dispensed as prescribed and how verification is done. The frequency of verification and how the verification is documented should be included in the policy and procedure. 9 It is recommended when there are multiple pill bottles of the same prescription that one pill bottle is completed before opening another pill bottle.

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

The agency is found in noncompliance because Youth A and Youth B’s interview state Staff 1 verbally prompted Youth A to go across the street to the lake and drown when she expressed suicidal ideation. CONSULTATION Girlstown youths may benefit from the option of live, in person appointments in conjunction with telehealth appointments.

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

The facility is found in non-compliance based on documentation reviewed, and interviews with Staff and Youths. There is sufficient evidence that Staff 2 used derogatory language and made negative references regarding a youth’s background.

Violation established, special investigation : CCI Rule 400.4150 Incident reporting

At the conclusion of the investigation, there was sufficient information to confirm non-compliance with licensing rule 4150-3. During the interview with the program manager, she confirmed the agency had failed to report AWOL and other critical incidents to the licensing authority and did not report them in MiSACWIS prior to 3/21/2024 as required.

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

Staff Person 1 admitted it was difficult to stay awake on midnight shift. 1/10/2024 video review from 2:26 AM to 3:17 AM shows Staff Person 1 completed a room check at 2:53 AM and at 3:14 AM, which is over 15 minutes. TECHNICAL ASSISTANCE Review and determine if midnight staff are permitted to wear headphones on duty. Revise policy and procedure as needed.

Violation established, special investigation : R 400.4109 Program statement

Staff 1 had 45 photos of Youth J on her phone. Agency policy indicates staff shall not take photos of youth.