Jackson-Feild Homes

Non-compliance, DBHDS investigation : 12VAC35-46-660. H. Entries in a resident's record shall be current, dated, and authenticated by the person making the entry. Errors shall be corrected by ...

Upon review of Individual #1's electronic health record, the provider failed to have documented evidence of current entry in Individual #1's record for the date of 7/20/2026, 7-3 staff, at the time of the inspection. The progress note for 7/20/2026-7 AM-3 PM shift was missing.

Non-compliance, DBHDS investigation : 12VAC35-46-750. B. (1) Individualized service plans shall describe in measurable terms the: 1. Strengths and needs of the resident;

Upon LS review of Individual #1's ISP, the provider failed to document elopement on the ISP.

Non-compliance, systemic, DBHDS investigation : 12VAC35-46-800. A. (2) There shall be evidence of a structured program of care designed to: 2. Provide protection, guidance, and supervision;

Upon LS review of Individual #1's record, documentation and interview, it is found that the provider failed to have evidence of a structured program of c care designed to provide protection, guidance and supervision. As documented in CHRIS#20260024, there was an elopement involving Individual #1. Individual #1 had been on Special Precaution measures prior due to prior incidents. AND Based on the provider's policy (Policy III-14.4-Special Precautions/Observation status), it is addressed that "Staff Alert-The resident must be checked visually by a designated staff member and charted on a staggered fashion with no more than 15 minutes between two checks; " "Eye View-Resident will remain within eye-view (line of sight) of a designated staff at all times and monitored by designated staff continuously with documentation every 10 minutes;" "Physician Ordered Supervision POS-Resident ordered POS precaution will remain within arms-length and in the line of view of the designated staff at all awake times. while in attendance of school, the resident on POS precaution will continue to be at arms-length of his/her POS staff at all times." AND Upon review of the providers 4.1-AWOL and Missing Persons policy, the provider addresses, AWOL is defined as at least one of the following: 1. Resident is off campus without permission and not within sight of staff; 2. Resident refuses to return to campus (as defined by the nurse.) 3. Resident reaches Wyatt's Mill Road and continues to walk/run ...

Non-compliance, DBHDS investigation : 12VAC35-46-800. C. The provider shall maintain a daily communication log to share information with staff about significant happenings or problems experienced ...

Upon review of the daily communication log, the provider failed to have documented evidence of maintaining a daily communication log to share information with staff about significant happenings or problems experienced by residents. The submitted pages of the daily communication log from 7/13/2026-7/20/2026, there was no communication of the AWOL attempt by Individual #1 during the 7-3 shift. The only notation was that Individual #1 was off campus to hospital at 3 PM.

Non-compliance, DBHDS investigation : 12VAC35-46-900. A. (1) Within 30 days of admission, the provider shall develop and implement a written behavior support plan that allows the resident to ...

Upon review of Individual #1's behavior support plan, the provider failed to address the need of Elopement in the plan.

Non-compliance, DBHDS investigation : 12VAC35-46-900. A. (3) Within 30 days of admission, the provider shall develop and implement a written behavior support plan that allows the resident to ...

Upon review of Individual #1's behavior support plan, the provider failed to have documented evidence of the required topic of "Identification of successful intervention strategies for problem behavior.

Non-compliance, DBHDS unannounced inspection : 12VAC35-46-450. A. Plumbing shall be maintained in good operational condition.

Upon LS inspection of the providers hot water temperature, the provider failed to have the hot water within regulation compliance of 100-120 degrees. The following temperatures were revealed during the inspection: Cottage #1 • Bathroom-Rm#16-hot water temperature was 138 degrees at the time of the inspection. • Bathroom-Rm#8-hot water temperature was 140 degrees at the time of the inspection. Cottage #2 • Bathroom-Rm#30-Hot water revealed a temperature of 123 degrees at the time of inspection. Cottage #3 • Bathroom-Rm#1-Hot water revealed a temperature of 77 degrees at the time of inspection. • Bathroom-Rm#2 (closest to laundry room)-Hot water revealed a temperature of 80 degrees at the time of the inspection. Cottage #4 • Bathroom-Rm#-7-Hot water revealed a temperature of 130 degrees at the time of inspection. Cottage #5 • Bathroom-Rm#5-Hot water revealed a temperature of 123 degrees at the time of inspection.

Non-compliance, DBHDS unannounced inspection : 12VAC35-46-590. B. The interior and exterior of all buildings shall be safe, properly maintained, clean, and in good working order. This includes, but is not ...

Upon LS physical environment inspection of the cottages, the provider failed to maintain the interior of the buildings in good working order. Please see below for each cottage inspection: Cottage #1 • Rm#19-Bathroom-Between the toilet and vanity, there is missing flooring beside the toilet. The fan vents are full of lint/dirt. The HVAC vent is dripping with condensation. At the base of the shower, the wood has water damage and wet mats remain in the floor. • Laundry Room-mop bucket in laundry room with dirty water in the bucket. Cottage #2 • Room #36-Door trim paint peeling and missing paint. • Room #39-HVAC vent is dirty. • Room #34-HVAC vent is dirty. • Room #30-Bathroom-Wet mat in floor at shower; door knob is bent sideways with toilet paper stuffed in door and on the door trim in attempt to hold the door closed. The faucet on the sink is loose. The fan vent is dirty with lint. • Room #27-Laundry Room-Sprinkler cover is hanging down from the ceiling above the entrance. • Dayroom-Clogged drain in the sink on both sides. • Milk carton with half full of milk, is warm and sitting on the counter. • The baseboard along the wall at the trashcan is dirty and their are slashes of liquid on the wall behind the large trash can. Cottage #3 • Bathroom Room #7-Food bowl in the sink with food particles in it. Personal items on the sink such as toothbrush, deodorant, etc. Light bulb over the sink is out. The ceiling light is going out and flashing erratically. There is a towel in front ...

Non-compliance, DBHDS human rights inspection : 12VAC35-115-175. F. (4) Additional requirements for complaints involving abuse, neglect, or exploitation: 4. The program director shall ensure that the ...

The program director shall ensure that the investigation is conducted by a person trained to do investigations and who is not involved in the issues under investigation. • During the Advocate's monitoring of the CHRIS entry A-20260010, the provider failed to provide evidence of investigations training for Employee #1. Based on the Advocate’s review, there is a preponderance of evidence to support the violation.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

Upon review of CHRIS entry A:20250026, the provider's investigation included staff admissions and a review of the provider's policy which revealed: • Individual #1 used playing cards to pick the door lock on the unit. • Individual #1 eloped from the unit undetected. • Individual #1 was spotted by an off-duty staff member who called 911. • Employee #1 failed to adequately supervise and monitor residents according to the provider's policy. Based on the provider's investigative finding, there is a preponderance of evidence to support the provider's substantiated finding of neglect.

Non-compliance, DBHDS investigation : 12VAC35-46-800. A. (2) There shall be evidence of a structured program of care designed to: 2. Provide protection, guidance, and supervision;

Upon review of Individual #1's documentation and interviews, the provider failed to have evidence of a structured program of care designed to provide protection and supervision. According to CHRIS #20250052, there was an incident involving Individual #1. Review of documentation of the incident revealed that Individual #1 was placed on "special precautions" weeks prior due to another incident. Based on the provider's policy (Policy III-14.4 Special Precautions/Observation Status), it states that "Staff Alert- The resident must be checked visually by a designated staff member and charged on a in a varied and staggered fashion with no more than fifteen (15) minutes between two checks", "Eye-View: Resident will remain within eye-view (line of sight) of a designated staff at all times and must be monitored by designated staff continuously with documentation every 10 minutes", and "Physician Ordered Supervision-POS-Arm's Length: The resident ordered POS precaution will remain within arms-length and in the line of view of the designated staff at all awake times. When the resident is asleep, the designated staff can sit in a chair just inside the resident's room by the exit door". Review of Individual #1's "Special Precautions Monitoring Form" revealed that Individual #1 was on "Staff Alert" from 12/01/25-12/02/25. Individual #1 was on "One to One" Special Precaution from 12/05/25 until the date of the incident (12/14/25) and then on "POS" Special Precaution on 12/22/25 to ...

Non-compliance, DBHDS human rights inspection : 12VAC35-115-110. C. (9a) - The provider's duties. 9. Providers shall comply with all applicable state and federal laws and regulations, certification and ...

Upon review of CHRIS entry A:20250027, the provider's investigation included an interview with Employee #1 and Individual #1 and a review of the provider's policy which revealed: • Employee #1 did not follow the proper behavioral management technique when restraining Individual #1. • Individual #1 received a laceration on the back of his neck. Based on the provider's investigative finding, there is a preponderance of evidence to support the provider's finding of a regulatory violation.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

Upon review of CHRIS entries, A:20250013, A:20250014, A:20250015, A:20250016, A:20250017, and A:20250018, the provider's investigation included a review of video footage and a review of the provider's policy. The OHR Advocate determined: • Employee #1 and Individual #1 engaged in "play wrestling" along with five peers including Individual #2, Individual #3, Individual #4, Individual #5, and Individual #6. • Employee #2 watched Individual #1, Individual #2, Individual #3, Individual #4, Individual #5, Individual #6 without redirecting the behavior. • Employee #1 and Employee #2 failed to follow the provider's supervision policy. Based on the provider's investigative summary, there is a preponderance of evidence to support the OHR Advocate's substantiated finding of neglect.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

Upon review of CHRIS entry, A:20250025, the provider's investigation included review of policy, which revealed: Employee # 1 did not follow the provider policy regarding the safe keeping of the TV remote, resulting in Individual # 1 swallowing two AAA batteries. Based on the provider's investigative finding, there is a preponderance of evidence to support the provider's substantiated finding of neglect.

Non-compliance, DBHDS investigation : 12VAC35-46-300. A. Separate up-to-date personnel records shall be maintained for each employee, student or intern, volunteer, and contractual service provider ...

Upon review of Employee #1's personnel record, the provider failed to have written documented evidence of a suspension without pay. The provider self admitted that Individual #1 had been suspended for 3 days without pay. The provider provided a "Corrective Action Plan" for the serious incident. However, there was no documentation in the personnel file related to the suspension and Individual #1 reported that she was not suspended.

Non-compliance, DBHDS investigation : 12VAC35-46-310. B. (1a) - Required annual retraining: 1. All employees, contractors, students and interns, and volunteers shall complete an annual refresher ...

Upon review of Employee #1's personnel file, the provider failed to have documented evidence in the file for retraining in emergency preparedness and response including alerting emergency personnel and sounding alarms. The last retraining was completed in 2023. Please provide documented evidence that Employee #1 has received retraining in emergency preparedness and response to include alerting emergency personnel and sounding alarms, for review.

Non-compliance, DBHDS investigation : 12VAC35-46-310. B. (1b) - Required annual retraining: 1. All employees, contractors, students and interns, and volunteers shall complete an annual refresher ...

Upon review of Employee #1's personnel file, the provider failed to have documented evidence in the file for retraining in emergency preparedness and response including implementing evacuation procedures. The last retraining was completed in 2023. Please provide documented evidence that Employee #1 has received retraining in emergency preparedness and response to include implementing evacuation procedures, for review.

Non-compliance, DBHDS investigation : 12VAC35-46-310. B. (1c) - Required annual retraining: 1. All employees, contractors, students and interns, and volunteers shall complete an annual refresher ...

Upon review of Employee #1's personnel file, the provider failed to have documented evidence in the file for retraining in emergency preparedness and response including using, maintaining, and operating emergency equipment. The last retraining was completed in 2023. Please provide documented evidence that Employee #1 has received retraining in emergency preparedness and response to include using, maintaining, and operating emergency equipment, for review.

Non-compliance, DBHDS investigation : 12VAC35-46-310. B. (1d) - Required annual retraining: 1. All employees, contractors, students and interns, and volunteers shall complete an annual refresher ...

Upon review of Employee #1's personnel file, the provider failed to have documented evidence in the file for retraining in emergency preparedness and response including accessing emergency information for residents including medical information. The last retraining was completed in 2023. Please provide documented evidence that Employee #1 has received retraining in emergency preparedness and response to include accessing emergency information for residents including medical information, for review.

Non-compliance, DBHDS investigation : 12VAC35-46-310. B. (1e) - Required annual retraining: 1. All employees, contractors, students and interns, and volunteers shall complete an annual refresher ...

Upon review of Employee #1's personnel file, the provider failed to have documented evidence in the file for retraining in emergency preparedness and response including utilizing community support services. The last retraining was completed in 2023. Please provide documented evidence that Employee #1 has received retraining in emergency preparedness and response to including utilizing community support services, for review.

Non-compliance, DBHDS investigation : 12VAC35-46-310. B. (2) Required annual retraining: 2. All staff who administer medication shall complete annual refresher medication training.

Upon review of Employee #1's personnel file, the provider failed to have documented evidence in the file for retraining in medication administration refresher. The last retraining was completed in 2023. Please provide documented evidence that Employee #1 has received retraining in emergency preparedness and response to include medication refresher, for review.

Non-compliance, DBHDS investigation : 12VAC35-46-310. B. (4) Required annual retraining: 4. All staff working with residents shall receive annual retraining in child abuse and neglect, mandatory ...

Upon review of Employee #1's personnel file, the provider failed to have documented evidence in the file for retraining in child abuse and neglect, mandatory reporting, maintaining appropriate professional relations and interaction among staff and residents and suicide prevention. The last retraining was completed in 2023. Please provide documented evidence that Employee #1 has received retraining in child abuse and neglect, mandatory reporting, maintaining appropriate professional relations and interaction among staff and residents and suicide prevention, for review.

Non-compliance, DBHDS investigation : 12VAC35-46-310. B. (5) Required annual retraining: 5. All staff shall receive annual retraining on the provider's policies and procedures regarding standard ...

Upon review of Employee #1's personnel file, the provider failed to have documented evidence in the file for retraining in Standard Precautions policy and procedures. The last retraining was completed in 2023. Please provide documented evidence that Employee #1 has received retraining in standard precautions policies and procedures, for review.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

"Neglect" means failure by a person, program, or facility operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, responsible for providing services to do so, including nourishment, treatment, care, goods, or services necessary to the health, safety, or welfare of an individual receiving care or treatment for mental illness, intellectual disability, or substance abuse. See § 37.2-100 of the Code of Virginia. Per the provider's investigative findings substantiate neglect as Employee #1, Employee #2, and Employee #3 did not provide appropriate supervision, leading to a peer to peer where Individual #1 became injured.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

"Neglect" means failure by a person, program, or facility operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, responsible for providing services to do so, including nourishment, treatment, care, goods, or services necessary to the health, safety, or welfare of an individual receiving care or treatment for mental illness, intellectual disability, or substance abuse. Upon review of CHRIS entry A20250001, the provider's investigation included an interview with Employee #1 and a review of the provider's policies which revealed: Employee #1 failed to follow the provider's supervision policy. Individual #1 swallowed a battery from the unit remote. Based on the provider's investigative finding, there is a preponderance of evidence to support the provider's substantiated finding of neglect.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

"Neglect" means failure by a person, program, or facility operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, responsible for providing services to do so, including nourishment, treatment, care, goods, or services necessary to the health, safety, or welfare of an individual receiving care or treatment for mental illness, intellectual disability, or substance abuse. See § 37.2-100 of the Code of Virginia. Per the provider's investigative findings conducted through interviews, the preponderance of evidence shows that Employee #1-#3 did not follow the policy regarding supervision of residents and do to not providing appropriate supervision, the peer to peer occurred, resulting in Individual #1 receiving a broken nose.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. D. (2) The provider's duties: 2. Providers shall develop, carry out, and regularly monitor policies and procedures that assure the protection ...

Per the provider's investigative findings, Employee #1- Employee #3 failed to follow policy, by not providing appropriate supervision to Individual #1.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

"Neglect" means failure by a person, program, or facility operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, responsible for providing services to do so, including nourishment, treatment, care, goods, or services necessary to the health, safety, or welfare of an individual receiving care or treatment for mental illness, intellectual disability, or substance abuse. See § 37.2-100 of the Code of Virginia. Per the provider's investigative findings, that Employee #1 failed to provide Individual #1 with 1:1 special precaution supervision during the time of the incident.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

"Neglect" means failure by a person, program, or facility operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, responsible for providing services to do so, including nourishment, treatment, care, goods, or services necessary to the health, safety, or welfare of an individual receiving care or treatment for mental illness, intellectual disability, or substance abuse. Upon review of CHRIS entries A:20240022 & A:20240023, the provider's investigation included an interview with Employee #1, Employee #2, Individual #1 and Individual #2. Additionally, a review of Individual #1's and Individual #2's service plan, a review of the provider's policies and a review of video footage which revealed: • Employee #1 failed to maintain 1:1 special precaution as outlined in Individual #1's Individual Service Plan. • Employee #2 failed to maintain 1:1 special precaution as outlined in Individual #2's Individual Service Plan. • Individual #1 and Individual #2 engaged in a physical altercation. Based on the provider's investigative finding, there is a preponderance of evidence to support the provider's substantiated finding of neglect.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

"Neglect" means failure by a person, program, or facility operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, responsible for providing services to do so, including nourishment, treatment, care, goods, or services necessary to the health, safety, or welfare of an individual receiving care or treatment for mental illness, intellectual disability, or substance abuse. Upon review of CHRIS entries A:20240020 & A:20240021, the provider's investigation included interviews with Employee #1, Employee #2, Employee #3, Individual #1 and Individual #2. A review of the provider's policies, a review of video footage and a review of Individual #1's Individual Service Plan which revealed: • Employee #1, Employee #2, and Employee #3 failed to maintain special precautions as outlined in Individual #1's Individual Service Plan. • Employee #1, Employee #2 and Employee #3 failed to follow the provider's policy regarding supervision. • Individual #1 and Individual #2 engaged in a physical altercation. Based on the provider's investigative finding, there is a preponderance of evidence to support the provider's substantiated finding of neglect.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

"Neglect" means failure by a person, program, or facility operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, responsible for providing services to do so, including nourishment, treatment, care, goods, or services necessary to the health, safety, or welfare of an individual receiving care or treatment for mental illness, intellectual disability, or substance abuse. Upon review of CHRIS entries A:20240020 & A:20240021, the provider's investigation included interviews with Employee #1, Employee #2, Employee #3, Individual #1 and Individual #2. A review of the provider's policies, a review of video footage and a review of Individual #1's Individual Service Plan which revealed: · Employee #1, Employee #2, and Employee #3 failed to maintain special precautions as outlined in Individual #1's Individual Service Plan. · Employee #1, Employee #2 and Employee #3 failed to follow the provider's policy regarding supervision. · Individual #1 and Individual #2 engaged in a physical altercation. Based on the provider's investigative finding, there is a preponderance of evidence to support the provider's substantiated finding of neglect.

Non-compliance, DBHDS unannounced inspection : 12VAC35-46-300. B. (5) The records of each employee shall include: 5. Annual performance evaluations;

Upon review of Employee #2's personnel file, the provider failed to have written documented evidence of an annual performance evaluation for Employee #2 in the personnel file. The last performance evaluation in the personnel file for Employee #2 was dated "5/15/2019-5/15/2020." Please address the citation with a corrective action plan of why the regulation was cited, how you will mitigate this regulation from being cited in the future, the staff member's position title for implementing the corrective action and the date that the corrective action will be implemented in the response.

Non-compliance, DBHDS unannounced inspection : 12VAC35-46-450. A. Plumbing shall be maintained in good operational condition.

Upon physical inspection of the sink faucet in bathroom #20 in the First Step Cottage, the provider failed to maintain the faucet in good operation. Upon moving the faucet, the water poured from under the handle and run down into the sink. Please address the citation with a corrective action plan of why the regulation was cited, how you will mitigate this regulation from being cited in the future, the staff member's position title for implementing the corrective action and the date that the corrective action will be implemented in the response.

Non-compliance, DBHDS unannounced inspection : 12VAC35-46-450. C. Precautions shall be taken to prevent scalding from running water. Water temperatures shall be maintained between 100°F and 120°F.

During physical inspection of the First Step cottage, the provider failed to maintain the hot water temperature within regulation compliance of 100-120 degrees. The First Step cottage hot water temperature check revealed a temperature of 142 degrees in rooms #19 and #20 which is above regulation compliance. Please address the citation with a corrective action plan of why the regulation was cited, how you will mitigate this regulation from being cited in the future, the staff member's position title for implementing the corrective action and the date that the corrective action will be implemented in the response.

Non-compliance, DBHDS unannounced inspection : 12VAC35-46-590. B. The interior and exterior of all buildings shall be safe, properly maintained, clean, and in good working order. This includes, but is not ...

Upon the physical inspection of 12/19/2024, the following issues were discovered with the interior of the buildings that did not promote safety, proper maintenance, and cleanliness. First Step Cottage: • Bathroom #19-The auxiliary fan/filter was dirty with noted lint showing through the ceiling fan. • Bathroom #20-The trashcan between the toilet and sink was overflowing with trash onto the floor. • Room #17-Ceiling appeared to have had something thrown on it or glued to it by the black marks that were present. • Room #15-There were dots on the ceiling that appeared to look similar to mold or mildew. • Chairs-The chairs in the dayroom appeared to be dirty or stained. • Handicapped bathroom-Upon entrance into the bathroom, there was a musty smell, with a towel lying down on the floor in front of the shower. Darden Cottage: • Laundry Room- Foul language written on the brown wall; • Washer-In the bleach dispenser on the inside and the inside of the tub ring there was noted black debris which appeared to be dirt and/or possible mold/mildew in the machine. • Chairs-The chairs in the dayroom appear to be dirty or stained. • Room #23-The door to the room was noted to have the paint peeling off the door. Marshall Cottage: • Bathroom #42-The toilet seat in the bathroom has the paint worn off of the seat in several places. • Laundry room-In the laundry room there is a medium size hole in the wall at the door. Gwaltney Cottage: • Room #8-This bedroom has a ensuite where the linoleum ...

Non-compliance, DBHDS human rights inspection : 12VAC35-115-110. C. (9a) - The provider's duties. 9. Providers shall comply with all applicable state and federal laws and regulations, certification and ...

Upon review of CHRIS entry 20240017, the provider's investigation included an interview with Employee #1 and Individual #1, a review of the provider's policies and a review of video footage which revealed: • Employee #1 implemented a physical hold that was not incompliance with the provider's standards. Based on the provider's investigative finding, there is a preponderance of evidence to support the provider's finding of a regulatory violation.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

"Neglect" means failure by a person, program, or facility operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, responsible for providing services to do so, including nourishment, treatment, care, goods, or services necessary to the health, safety, or welfare of an individual receiving care or treatment for mental illness, intellectual disability, or substance abuse. Upon review of CHRIS entry 20240017, the provider's investigative summary included an interview with Individual #1 and Employee #1, a review of the provider's supervision policy, and a review of video footage. OHR Advocate determined: • Employee #1 failed to follow the provider's supervision policy. Based on the provider’s investigative finding, there is a preponderance of evidence to support the OHR Advocate’s finding of neglect.