Let’s Talk About It Girl’s Home II

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

The facility is found in violation as Staff 1 reported she did not follow the Medication Procedure and did not check the name on the medication pack or compare the medication listed to the Medication Administration Record. This action ultimately resulted in Youth A taking Youth C’s medication and sought medical treatment due to the ingestion of incorrect medication. When Staff 4 passed Youth A her medications and there was a double dose of her night medication, this was caught before Youth A was able to ingest the incorrect medication.

Violation established, special investigation : R 400.4112 Criminal history check, subject to requirements;

The facility is found in noncompliance as evidenced by interviews with staff, youth, and documents reviewed. Evidence strongly supports the allegation of Staff 2 providing marijuana gummies to Youth A and Youth B since youths admitted to the allegations and Law Enforcement report documents Staff 2’s admission. TECHNICAL ASSISTANCE: Technical assistance was offered regarding this situation. The facility reports not drug testing employees since marijuana is currently legal in the State of Michigan. It was suggested they 6 either begin drug testing possible employees or at the minimum question the potential employee about use of marijuana. Technical assistance was offered regarding the importance of staff understanding their role at the facility. Staff should understand their primary role is as a healing agent. Staff should understand they can develop an emotional bond to these youth but must guard themselves from a destructive bond which negatively impact youth. This should be a topic at each staff meeting and staff should be keeping each other in check on this topic.

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

The facility is found in violation as per interviews conducted and documentation reviewed, Youth A’s medications were not passed correctly as she was not given all her evening medications on 3/27/25 despite it being documented she was. Although it is not clear what happened to the missing medications, it is evident, some of Youth A’s medications from 3/28/25 and 3/29/25 were punched out of the medication packet prior to the days/times for those medications occurring.

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

The facility is found in non-compliance as evidence by interviews with staff, youth and video recording review. Staff 1 did not follow the policy that staff are to leave personal items in the locked office when working at the facility. This action by Staff 1 allowed Youth A to obtain medication and attempt a self-harming behavior. Staff 1 also failed to follow the safety plan (2/9/25) which states staff are to remain within an arm’s length of Youth A “at all times”. TECHNICAL ASSISTANCE: Technical Assistance was offered to the facility to monitor Staff 1 more closely. Because Staff 1 is a newer staff, she should not have full responsibility for any youth without another staff being present. All staff working with Staff 1 should be required to complete an evaluation form after 1 month to ensure Staff 1 is following all the expectations of a direct care staff at the facility.

Violation established, special investigation : R 400.4158 Intervention standards and prohibitions.

The facility is found in non-compliance as evidence by interviews with staff, youth and video recording review. Administrator 1 reported observing Staff 1 and Staff 3 engage in inappropriate touching/pushing of Youth A and Youth B when trying to keep them from fighting. TECHNICAL ASSISTANCE: Technical Assistance was offered to the facility to train all staff with physical management techniques. This would allow staff to engage in physical management as a last resort to keep youth safe.

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

The agency is found in non-compliance as per interviews conducted, video footage reviewed, and documents reviewed, Staff 3, Staff 6, and Staff 8 did not complete bed checks as required. In addition, Staff 3 and Staff 6 were seen sleeping on shift. Technical Assistance Technical assistance was offered to the agency that staff must ensure they are completing bed checks at variable intervals. There were multiple checks documented on bed logs that were 12 or 15 minutes exactly for most of the shift. 8 Consultation Consultation was offered to the facility on 4/19/24 regarding moving the living room chair out from underneath the camera’s view to ensure staff can be seen on camera.

Violation established, special investigation : 722.120

The agency is found in non-compliance as per documentation and video footage reviewed, Staff 3 and Staff 6 documented bed checks which did not occur or bed checks occurred, but they did not document the times of completion accurately.

Violation established, special investigation : R 400.4431 Heating equipment

The facility is in violation of the rule as the temperature was observed to be at 61 degrees on the main floor. The Chief Administrator acknowledged that this was due largely to the inadequate furnace, which was replaced. A CAP is still required.

Violation established, special investigation : R 400.4552 Heating devices and flame producing devices

The facility is in violation of the rule as they were using a portable, electric fireplace space heater in the living room to assist with heating the area. The fireplace was disabled; however, a CAP is still required.