Highfields

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

The facility is found in noncompliance with the rule as it was found within interviews and video review that Staff 1 did not perform a restraint on Youth A in an approved, safe manner. It was found that Staff 1 did place his arm around Youth A’s neck for a short period of time, which is not a safe restraint technique. It should be noted that Staff 2 noticed Staff 1’s hold was inappropriate and redirected him right away. Staff 1 immediately disengaged the unsafe hold and stepped away from the situation. Technical Assistance When reviewing the facility’s behavior management policy that the section for prohibited techniques does not address all the points outlined within state licensing rule R400.4158 (1) (a) (i-v). This consultant provided technical assistance to the facility to update their policy to incorporate all prohibited techniques that are noted in the licensing rule.

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

The agency is in violation of this rule. Staff 1 admitted to pushing Youth A.

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

The facility was found in non-compliance as per staff and youth interviews and video review, Staff 1 pushed Youth A multiple times and threw Youth A to the side during the escalated incident that occurred on 05/18/2024. Consultation provided: Consultation was provided in the area of best use of staff during an escalated incident. This incident involved a restraint attempt initiated by Staff 1 when Staff 1 was directly involved in the original escalation of Youth A. In addition, staff involved felt that Staff 2 would not be able to attempt to de-escalate the situation. Youth A may not have been able to benefit from any staff’s de- escalation attempts at that point but it should be considered and explored in staff meetings and trainings how staff can avoid situations with youth escalated specifically at them and how other staff can assist in their stead.

Violation established, special investigation : CCI Rule 400.4132 Grievance procedures

The facility is found in non-compliance as there was evidence found the facility did not act on a provided grievance in a timely manner, specifically not meeting the two day requirement set out in facility policy.

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

At the conclusion of the investigation, the agency was found to be in noncompliance with licensing rule 4158 due to Staff 1 engaging in horseplay and using physical activity with Youth A. Review of video footage and interviews with youth and staff confirmed that non-compliance with the rules occurred.

Violation established, special investigation : R 400.4126 Sufficiency of staff

At the conclusion of the investigation, the agency was found to be in non-compliance with licensing rule 400.4126. Staff did not provide for the continual needs, protection, and supervision of youth when a teacher who is not employed by the facility was left alone with the youth.

Violation established, special investigation : CCI Rule 400.4109 Program statement

The agency was found to be in non-compliance with licensing rule 4109-1-C. Agency failed to follow their written policy regarding the completion of incident reports. 12

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

At the conclusion of the investigation, it was found that the agency was in non-compliance with licensing rule 4131. After witnessing the incident firsthand and watching video of the incident, none of the staff reported the incident as required by the child protection law.

Repeat violation established, special investigation : CCI Rule 400.4159 Youth restraint; pregnant youth; reduction, prevention; prohibited restraints; elimination of restraints.

Through interviews with youth and staff and documentation reviewed there was evidence found to show that Youth A was restrained in a prone position during two different parts of the escalated incident that occurred on 09/28/2023 and staff did not immediately disengage. Technical Assistance provided: • The facility is advised to update their restraint training materials and policy to eliminate any positions or mentions of a youth in a prone position on the ground. In addition, review and editing of restraint training should occur to clarify what kinds of restraint efforts would be approved for youth on the ground in a supine position so that staff are 7 confident in the moment when they need to attempt to perform this restraint. • The facility is advised to focus training on their chosen restraint model to ensure that rule 400.4159 (6) is met even during the most escalated incidents, allowing youth to be restrained only for the minimal time needed for the youth to calm down and restore safety.

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

Through interviews with youth and staff and documentation reviewed there was evidence to find the Incident Report written for the 09/28/2023 incident involving Youth A did not contain accurate information.

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

At the conclusion of the investigation, the agency was found to be in noncompliance with licensing rule 4158 due to Staff 1 engaging in horseplay and using physical activity with Youth A. Review of video footage and interviews with youth and staff confirmed that non-compliance with the rules occurred.

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 400.4127. The staff did not maintain staff to youth ratio as required per their policy and left a teacher who is not employed by the facility alone with the youth.

Violation established, special investigation : CCI Rule 400.4109 Program statement

The agency was found to be in non-compliance with licensing rule 4109-1-C. Agency failed to follow their written policy regarding the completion of incident reports.

Violation established, special investigation : CCI Rule 400.4112 Criminal history check, subject to

At the conclusion of the investigation, the agency was found to be in non-compliance with licensing rule 4112-2-b. The agency hired an employed with an active warrant and felony conviction within the last year.

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

At the conclusion of the investigation, it was found that the agency was in non-compliance with licensing rule 4131. After witnessing the incident firsthand and watching video of the incident, none of the staff reported the incident as required by the child protection law. 13

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

Staff 2 physically assaulted Youth A. Supervisor 1, Staff 1, and Youth A all confirmed a physical assault between Youth A and Staff 2. 5 TECHNICAL ASSISTANCE: I reviewed Staff 2’s Job Description Details signed by him. Staff 2 was hired specifically as an “Overnight Worker” with a “Decision Making” level at a “low level, 2 on a 10 point scale.” Staff 2 was hired to monitor youth at overnight hours and the success in completing that job is based on the ability to, “supervise an assigned house or campus during overnight hours, familiar with and practice current agency policies…take necessary precautions for students identified as high risk and provide oversight of them as prescribed…maintain good communication with day staff through exchange of relevant information…maintain alert and close supervision of students until properly relieved by regularly assigned staff…” Staff 2 was specifically hired to work overnight hours. Administrator 1 did report that, afternoon direct care workers have a different job description. Administrator 1 reported they do use overnight workers in afternoon shifts at times. Administrator 1 reported this is how they promote from within as well. Staff 2 does not have an afternoon direct care job description in his file. The agency allowed an overnight worker to fill a role that he was not hired for. If the agency would like to permit overnight workers to work afternoon shifts, then the agency will need to update their “Overnight Worker Job Description” ...

Violation established, special investigation : CCI Rule 400.4158 Interventions and Prohibitions

Supervisor 1, Staff 1, and Youth A all reported Staff 2 made verbal threats and threatening gestures towards staff and Youth A. Staff 2 made derogatory comments towards the staff on site and challenged Youth A to a physical fight.

Repeat violation established, special investigation : R 400.159 Resident restraint

Staff 1 restrained Youth A even though he was not trying to injure anyone. Staff 1 admitted he misread the situation. The video showed Youth A was not posing a risk to anyone when he was restrained. The restraint Staff 1 utilized on Youth A was not performed in a safe manner. The video showed Staff 1 straddling Youth A with one knee on Youth A’s shoulder and holding Youth A’s jacket over his face.

Violation established, special investigation : Residential Critical Incidents

The facility is found in noncompliance of the requirements for documenting incidents into the MiSACWIS system.

Repeat violation established, special investigation : R 400.4159 Resident restraint

Although there was not consistent evidence to support Staff 3 had his knee on Youth A’s back and twisted Youth A's arm, the facility is found in non-compliance as Staff 3 did not use proper restraint technique. Technical Assistance: The facility followed their protocol in response to Youth A reporting he was injured. However, it is recommended the facility protocol be updated to include a medical professional assessment be obtained if a youth reports an injury. Additionally, the facility’s nurse recently resigned. The facility is aware this is a required position and will continue to work to replace the position.

Violation established, special investigation : JRM 610 Youth Restraint

The facility’s policy is in direct violation of their Residential Foster Care Juvenile Justice (RFCJJ) contract. The contract refers to JRM 610 which does not allow for a restraint to occur for

Repeat violation established, special investigation : R 400.4112 Criminal history check, subject to requirements; staff

Staff 3’s was substantiated for child physical abuse.

Repeat violation established, special investigation : R 400.4159 Resident restraint

Youth A is escalated by staff, restrained in an unsafe location, and restrained in prone restraint with Staff 2 lying on top of him. This is not a safe way to perform a restraint also, prone restraints are not allowed in Child Caring Institutions (CCI) due to the safety risk they impose.

Repeat violation established, special investigation : Rule 1 Prohibition of Prone Restraint; Procedures Involving

The facility is in violation of the rule as they did not follow their policies and procedures related to physical management.

Violation established, special investigation : Rule 2 The written policy must include all of the following:

The facility is in violation of the rule, as the incident report was a brief summary of the hours long incident but did not identify the staff holding Youth A in a prone position multiple times, lifting/carrying Youth A, or pulling Youth A by his leg from under the kitchen table. Supervisor 1 signed off on the incident report, which was authored by Staff 2 who observed most of the incident, and was also reviewed by the Manager, who had also reviewed the video. The facility’s policy calls for staff to file factual, timely, and complete incident reports.