Havenwyck Hospital Residential Impulse Disorder Program

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

Allegation 1: The agency is found to be in non-compliance based on video review and staff interviews. At the time of the incident, multiple youth were present hanging out in the short hallway. Staff 2 was present and seated outside the bedrooms; however, the video shows his back was turned toward Youth B, and he did not turn around until the physical altercation began. Staff 6 also had line of sight to the youth. Staff 2 reported during his interview that he was on the long hallway with Staff 5, which is inconsistent with the video footage. Both Staff 2 and Staff 6 intervened immediately once the fight began. However, staff allowed youth to hang out in the hallway without direct supervision giving them time to plan and execute the assault on Youth C. Allegation 2: The agency is found in compliance as per video review. Staff are observed engaging and supervising the youth that were in the hallway. Because of this they were able to quickly intervene in the altercation. Allegation 3: The agency is found in compliance as per video review. Video review showed staff present in the hallway actively supervising the youth prior to altercation, which allowed them to intervene immediately. Allegation 4 and the Additional Allegation: The agency is found in non-compliance based on video review, staff interviews, and youth interviews. Two incidents involved Youth A going AWOL. Video review showed Youth A exited the building on 5/18/26 and remained outside for approximately five minutes ...

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

The agency is found in non-compliance. Based on the records reviewed and the documentation provided, Staff 1 and Staff 12 did not have current CPI training at the time the incidents took place.

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

Incident 1 – 5/19/26: The facility is found in violation for failing to follow its approved restraint technique/procedure when Staff 9 physically intervened with Youth H during the altercation involving Youth E, Youth F, Youth G, and Youth H. Staff 9 is observed wrapping both arms around Youth H’s torso and repeatedly pushing and pulling him toward a bedroom doorway until Youth E exits the hallway. Staff 9’s intervention constituted a restraint; however, he did not complete the full approved NCI restraint technique. Incident 2 – 5/17/26: The facility is found in violation for failing to follow its approved intervention/restraint procedures when Staff 3, Staff 12, and Staff 13 physically intervened to separate Youth H from Youth I during the altercation. Staff 13 is observed pulling Youth H by the back of his shirt to move him away from Youth I and later pushing and pulling him away. Staff 3 is observed holding Youth H by the arm and pulling him backward. Staff 3 later holds Youth H around the waist while Staff 12 holds Youth H’s hands from the front. Staff 13’s pulling Youth H by the shirt was not an approved CPI intervention. The intervention used by Staff 12 was not an approved disengagement or redirection technique. The CPI techniques described in the manual require specific positioning and contact with the child’s arms, forearms, elbows, or wrists, depending on the level of restriction. The approved techniques do not describe pulling a youth by the shirt, controlling 28 ...

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

The agency is found in non-compliance based upon staff interviews, video review, interviews with CA and Program Director, review of the NCI Advanced Skills/CPI training materials, and the definition of personal restraint. This review identified interventions in Incident 1 and Incident 2 in which disengagement/separation escalated into personal restraint. In Incident 1, Staff 8 restricted Youth G's movement by maintaining physical control of him, and Staff 9 held Youth H while he attempted to break free and return to the altercation. In Incident 2, Staff 3 and Staff 13 held Youth H around the waist, restricting his movement while he attempted to return to the altercation. Although the agency characterized the interventions as disengagement and redirection, the identified physical holds meet the definition of personal restraint because physical force was used to restrict the youths' free movement. The agency did not identify these interventions as restraints and, as a result, restraint incident reports were not completed in MiSACWIS.

Violation established, special investigation : CCI Rule 400.4538 Means of egress

The agency is found in non-compliance per staff interview and completed unannounced walkthrough. The two non-operational egress doors posed serious safety concerns for youth and staff. Although the egress door by the secure rooms was repaired and secured so that youth can’t walk out of the facility, the door couldn’t be opened due to a missing door handle which is a safety concern in the event of a fire. The egress door on the short hallway could not be opened due to staff keys not working. Additionally, staff were unaware the egress door couldn’t open until the unannounced walkthrough was conducted. The agency did make repairs immediately, so both egress doors were operational. Furthermore, the agency did create and revise walkthrough forms to ensure all doors are operational and working correctly. Technical Assistance Technical assistance was offered regarding the hallway door that separated the youth bedrooms and classroom and the hallway with the secure rooms. It was recommended that prior to installing that door, a BFS plan needs to be submitted and approved.

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

The agency is found in non-compliance based on staff interviews and video review. Staffing was not consistently sufficient to ensure adequate supervision, protection, and timely intervention for youth. Staff interviews revealed the facility experienced limited coverage during high-risk periods at times, including medication passing and room changes. Staff also reported situations where available staff were unable to effectively manage multiple youth who were engaged in behaviors that escalated to altercations. In two sperate instances seen on video Staff 1 did not demonstrate a sense of urgency when intervening in the physical altercation involving youth. Due to the number of youth in the hallway on 4/8/26, Staff 2 was unable to provide sufficient supervision. Once Youth C and Youth F went to their rooms, Staff 2 was no longer able to adequately 10 supervise all youth simultaneously. Additionally, Youth F was left without direct staff supervision, as Staff 2 reported she was not assigned to supervise Youth F. Technical Assistance: Technical assistance was offered regarding incident report documentation. It was observed that incident reports were not consistently completed in their entirety, as required information such as dates, incident report numbers, and staff signatures were missing. The agency was advised to ensure all incident reports are fully completed, accurate, and properly documented.

Violation established, special investigation : CCI Rule 400.4407 Facility and premises maintenance

The agency was found in non-compliance per staff and youth interviews. During, multiple visits to the facility, damaged walls, exposed insulation and wiring, missing drywall and ceiling tiles were observed. Several windows and walls were covered with plywood, including bedrooms, classrooms, common areas, and the lobby. One lobby door was bolted shut and did not work properly. Photos, interviews, and records showed many repairs were delayed, including repairs to smoke detectors and damage in 20 youth bedrooms. Staff and youth also reported damage caused by youth was not always repaired quickly. During the investigation, some of the damages were repaired however, given the timeframe it took to rectify the damages, the building conditions created safety concerns making the facility not consistently safe for the youth living there. Technical Assistance: The facility should implement an alternative therapeutic intervention for youth who require a safe method for emotional regulation and redirection of aggressive behaviors. Storing extra mattresses in youth bedrooms for punching purposes is not an appropriate practice due to limited space in the bedrooms. The facility should identify and utilize more suitable alternatives designed for this purpose, such as approved sensory or therapeutic equipment, while ensuring youth sleeping areas remain free from unnecessary items and safety hazards.

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

The agency was found in non-compliance based upon Staff 2’s interview and video review. Video footage showed prior to and at the onset of the incident between Youth C and Youth F, there were six youth under the supervision of Staff 2. The required staff-to- youth ratio is 1:5. Therefore, the ratio requirement was not met, as one staff member was responsible for supervising six youth.

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

The agency was found to be in non-compliance. Based on the video review, there were not enough staff on the floor to adequately supervise the youth and ensure the protection of Youth A and Youth E during the incidents. At the onset of the altercation, Staff 3 remained seated and did not immediately intervene, which allowed 12 the situation to escalate. Similarly, during Youth A’s incident, Staff 1 remained seated outside of Youth A’s room while multiple youth gathered in the hallway and repeatedly approached and looked into the room, without redirection, until things escalated. This lack of immediate intervention contributed to the escalation, as Youth B and several other youth were able to push past staff and enter Youth A’s room. In both situations, staff were unable to effectively control youth movement or prevent unauthorized entry into resident rooms. Additionally, following the incidents, several youth remained in the hallway without appropriate supervision or redirection. In the Youth A incident, youth continued to gather and stand near the doorway even after this incident. This further demonstrated that staff coverage was inadequate to ensure continued safety and control of the environment.

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

The agency was found to be in non-compliance. The incident involving Youth F occurred on 3/30/2026 which resulted in law enforcement contact on 3/31/2026. Although the agency notified the assigned case manager, The DCWL consultant was not notified of law enforcements contact or Youth F injuries from the incident on 03/30/2026.

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

The agency was found to be non-compliant based on video review. The footage showed two unidentified youths engaging in a peer-on-peer restraint of Youth F. Staff present did not immediately intervene or redirect the youths. One unidentified youth stood behind Youth F and held his arms behind his back until staff redirected Youth E back to his room.

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

Allegation 1 The agency is found in noncompliance in providing for the needs, protection, and supervision of the youths on the short hallway during this incident. Milieu Speciliast, Staff 1, Staff 2, and Staff 3 worked to de-escalate Youth A, Youth B, Youth C, and Youth D, but assistance staff took approximately eight minutes to respond, which is untimely, in an escalating situation. The delay in assistance staff arriving left the other youths on the short hallway unattended. CONSULTATION Consider moving administrative staff who are trained in physical management from the Havenwyck Hospital location to the Havenwyck Impulse Disorder Program to improve the availability and timeliness of staff to intervene in emergency situations. Allegation 2 The agency is found in compliance in providing for the needs, protection, and supervision of Youth D and the youth on the long hallway being targeted by Youth D. Youth D did not break the door window and get on the long hallway.

Violation established, special investigation : CCI Rule 400.4407 Facility and premises maintenance

The agency is found in noncompliance in maintaining a clean, comfortable and safe condition. Youth A’s bedroom was not found clean and the nursing station repairs were not completed timely from the damage done in 12/2025 and 02/2026. CONSULTATION Please review R 400.4505 Plans and specifications and obtain required Bureau of Fire Safety review and approval as required.

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

There is a rule violation established regarding the above allegation. Per interviews and viewed video footage of incidents #1, #2, #3, and #4, youth were permitted to roam the building and plan and carry out assaults without staff intervention. Even after youth engaged in an assault with one youth they were allowed to wonder the hallway allowing them to assault another youth. Consultation: It was discussed throughout the course of the investigation physical restraint should be utilized in situations of physical assault of other youth to prevent injury.

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

An additional finding of non-compliance is established. Per viewed video footage Staff 2 places his left arm against Youth K’s chest and pushes him which is a prohibited intervention.

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

Allegation 1: The facility was in compliance with there policy as they provided both the policy and incident reports for all 4 incidents. Allegation 2: The facility is found in non-compliance. Based on video footage staff are seen on their cell phones when they are supposed to be supervising and engaging with youth and prior to any emergency situation. This is in direct violation of the facility’s cell phone policy. Allegation 3: The facility is found in non-compliance as it was seen on video that youth were freely entering each other’s bedrooms without any staff intervention or engagement.

Repeat violation established, special investigation : CCI Rule 400.4127

The facility was found in non-compliance as video footage from Incident #4 showed there were at least 7 youth seen in the classroom with 1 staff member. Additionally, video of the hallway outside the classroom showed a constant flow of youth in the hallway with a varying number of staff. There is a violation regarding allegation #3. Per video footage of incident #4, there are at least 7 youth seen in the classroom with 1 staff. Additionally, in review of Video #2 of the hallway outside of the classroom during the time incident #4 occurred, there is constant flow of more than 5 youth in the hallway and at times only 1 staff.

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

The facility is found in violation as per interviews conducted, video footage reviewed, and documents reviewed, Staff 2 and Staff 3 did not follow supervision procedures such as positioning themselves in the hallway to have sight of all youth and keeping line-of-sight of Youth A since he was on sexual acting out precautions. These actions resulted in two youth entering a bedroom unsupervised and engaging in sexual activities with each other. TECHNICAL ASSISTANCE: • If the facility is going to have youth “hang out” in bedroom hallways during transition times between activities, there should be an established procedure for how that is done to ensure safety for youth. For example, staff positioning in hallways to ensure appropriate supervision, youth sitting 8 down in the hallway instead of walking around to mitigate chaos & increase sight of youth, etc. • Safety plans should always be in writing, even if a youth is on sexual acting out precautions, and the written safety plans/precautions must be in an accessible area for staff to access and review. For example, some facilities require staff to sign off on each youth’s safety plan when they clock in at the beginning of their shift each day. This will ensure proper knowledge of each youth’s specific needs so staff can tailor their supervision of youth accordingly each shift.

Repeat violation established, special investigation : CCI Rule 400.4128 Initial staff orientation and ongoing staff

The facility is found in violation as per interviews conducted and documentation reviewed, Staff 2 and Staff 3 were not provided with a residential-specific orientation prior to being assigned to cover shifts and assume duties at the facility. TECHNICAL ASSISTANCE - The facility was advised even though there was an urgent need for staff, assigning staff to cover residential shifts when they did not have residential-specific orientation or training is a safety issue for youth and staff, as well as a liability for staff and the facility. The facility should ensure there is a specific process for training hospital staff who cover shifts at the residential facility and those staff should not be assigned to a residential shift until training is completed. - The facility should consider increasing leadership support for the unit, especially when there are new staff and hospital staff covering the same shift. In this situation, there were three staff on shift – two of whom were untrained on residential policies/procedures/supervision/safety plans and 13 one who had begun working at the facility less than 90 days prior to the incident. - The facility must include all supervision requirements, safety plans/SAO precautions, and bedroom door policy, in orientation/training for all staff, including hospital staff covering shifts. - If youth are allowed to shower in bathrooms in other youths’ bedrooms, there should be specific training and procedures surrounding this process to ensure ...

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

The facility is found in violation as per interviews conducted, video footage reviewed, and documents reviewed, Staff 2 and Staff 3 did not follow the Residential Treatment Center Door Safety 15 policy, which resulted in two youth entering a bedroom unsupervised and engaging in sexual activities with each other. TECHNICAL ASSISTANCE: • If youth are given the choice to eat meals or snacks while sitting on the bedroom hallway floor versus in a dining area or table, that should be documented to ensure understanding this is a choice by each individual youth and not a requirement due to the facility’s lack of dining space.

Violation established, special investigation : CCI Rule 400.4116 Chief administrator; responsibilities

The facility is found in violation as per interviews conducted and documentation reviewed, CA has failed to meet the requirements of being responsible for the on-site day-to-day operation of the 21 facility and ensuring compliance with licensing rules. As a result, youth and staff have been put into unsafe situations, which have been unnecessary and avoidable. TECHNICAL ASSISTANCE: - The facility should update their SAO policy to include the role of leadership in establishing and enforcing precautions as well as outline the process for how and when staff are to be notified of the precautions for each youth.

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

The agency is found in noncompliance for not completing the medication order documentation for Youth A’s 12/22/2025 Benadryl and Haldol injection until 01/14/2026. CONSULTATION Review how a doctor’s order for as needed injection is being coordinated, documented, dispensed, and monitored at Havenwyck Impulse Disorder Program when administered by Havenwyck Hospital nurse.

Violation established, special investigation : CCI Rule 400.4505 Plans and specifications

There is a rule violation established regarding this allegation. Per email dated 1/9/2026 BFS approval is still pending. The facility began work requiring BFS Plan approval prior to receiving the approval.

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

The agency was found to be non-compliant based on staff and youth interviews, as well as a review of video footage. Staff 1 acknowledged pushing Youth A in an attempt to de-escalate the situation and protect herself; however, physical contact in the form of pushing a resident is prohibited under the agency’s Behavior Management Protocol and applicable CCI regulations. Consultation: Consultation was offered to the agency to retrain staff on the proper implementation of the “Tap Out” method. Multiple staff members were on shift during the incident and could have intervened to support Staff 1, potentially preventing the escalation with Youth A. Staff were advised to be retrained on the required procedures to follow if a youth had physical contact with an employee. The agency was advised to update its internal physical restraint protocol to ensure it was clear, concise, and consistently followed by all employees. Technical Assistance: Technical assistance was provided to ensure that all staff training certificates and verification documents reflect complete training dates, including the month and day, rather than listing only the year.

Violation established, special investigation : CCI Rule 400.4131 Compliance with child protection law; development of plan

The agency was found to be non-compliant because the incident involving Youth A and Staff 1 occurred on 10/19/2025 and was not reported or documented in an incident report until 10/24/2025. This delay did not comply with child protection law, which requires suspicion of abuse/neglect to be reported immediately. The Chief Administrator and Program Manager both reported that the agency did not have an internal policy outlining the required protocol for completing incident reports or reporting incidents of suspected child abuse or neglect, which contributed to the failure to document and report the incident in a timely manner. Technical Assistance: The agency is to implement written policies that provide clear 11 guidance to employees regarding when an incident report must be completed and when/how/who makes a report of suspected abuse/neglect.

Violation established, special investigation : CCI Rule 400.4150 Incident reporting

The facility is found in non-compliance as evidenced by interviews and documents reviewed. The facility did not report to state licensing that police were contacted due to the behaviors of the youth. Technical Assistance This consultant recommends the facility create their own policy as it pertains to incident reporting that is in full compliance with this rule. The policy should note who will be completing the reporting, who is being reported to, and what timeframe the reporting needs to be completed in.

Violation established, special investigation : CCI Rule 400.4126 Sufficiency of staff

The facility is found in non-compliance of sufficiency of staff as it was reported within several interviews staff felt there were not enough staff there to support the behaviors of the youth. The facility did follow the guidelines to call in extra support but due to the behaviors of the youth, there wasn’t a sufficient amount of staff to support the needs of the youth.

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

The agency is found in noncompliance when Former Staff 1’s right palm connects with Youth A’s forehead during an incident on 11/04/2025.

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

A rule violation is established regarding this allegation. It was consistently reported and observed in video footage that Staff 1 did not have line of sight of Youth A while in the back hallway from his position in the main hallway. The supervision policy for all residents is direct line of sight for all youth at all times.

Violation established, special investigation : CCI Rule 400.4128 Initial staff orientation and ongoing staff training

A rule violation is established regarding this allegation. Per licensing rules all staff must receive at least 16 hours of orientation, and a total of 50 hours of training in their first year. Training transcript for Staff 1 totals 23:48 hours which includes all training for work in the affiliate hospital and not for the residential program, and 8 hours of orientation from 1/1/2024 to 11/12/2025.

Violation established, special investigation : CCI Rule 400.4109 Program statement

The agency was found to be in non-compliance based on staff interviews and a review of the available documentation. According to facility leadership the facility does not have an incident reporting policy.

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

The facility is found in noncompliance as per video review, Supervisor pushed Youth A.

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

The facility is found in noncompliance as per staff interviews and video review, the proper team control restraint technique was not used by Staff 1 and Staff 2. CONSULTATION: Consultation was offered to retrain staff on CPI techniques and how staff can better assist one another during interventions and restraints. It is also recommended the facility review the restraint videos with staff as a training tool to discuss how to better get in the correct position when youth are spitting and punching at staff.

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

At the conclusion of the investigation, the agency was found to be in non-compliance with the licensing rule. Upon arrival of the consultant for both unannounced and announced agency visits, staffing ratio was not consistent with agency policy.

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

At the conclusion of the investigation, the agency was found to be in non-compliance with licensing rule. Review of supervision logs confirmed that agency failed to document variable interval checks when youth were outside direct supervision of staff.

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

At the conclusion of the investigation, the agency was found to be in non-compliance with the licensing rule. Review of medical logs confirmed that the agency failed to dispense medication to youth as prescribed.