Mountain Meadow Youth Ranch

Deficiency cited, renewal inspection

The Surveyor’s review of participant records on July 22, 2025.

Deficiency cited, renewal inspection

The record for one out of three participants (Participant #3) did not contain: (b) verification of the father having sole legal authority to place or remove the participant from the program, and (e) an initial assessment of the program participant's emotional, medical, developmental, social, and behavioral status at the time of admission. Repeat deficiency, 2023 plan of correction not followed. The surveyor’s review of participant records, participant interviews and staff interviews on July 22, 2025.

Deficiency cited, renewal inspection

• Six out of six youth interviewed report that the communication policy is not being followed. Calls are not confidential and occur in the living room with other participants and staff present. The calls are not always video telephonic. The weekly calls occur on Sunday and are canceled if there is work to be completed on the ranch. The calls are

Deficiency cited, renewal inspection

• Discharge documentation for discharged program participants was requested both onsite and requested to be sent electronically following the onsite visit. No discharge documentation was received by the facility. Repeat deficiency, 2024 plan of correction not followed. The surveyor’s review of participant records on July 22, 2025.

Deficiency cited, renewal inspection

• The initial case plan for one out of three participants (Participant #3) was not completed within 7 days of admission. The date of admit was 05/09/2024 and the plan was completed on 05/20/2024. Repeat deficiency, 2023 plan of correction not followed. The surveyor’s review of participant records and participant interviews on July 22, 2025.

Deficiency cited, renewal inspection

• Six out of six participants interviewed report that parents/guardians are not involved in case planning . Case planning is conducted between the participants and Staff #4 only. The surveyor’s review of participant records on July 22, 2025.

Deficiency cited, renewal inspection

• The record for one out of three participants (Participant #3) did contain documentation that a copy of the treatment plan dated 05/20/2024 was provided to the parent/guardian. Repeat deficiency, 2022 and 2023 plans of correction not

Deficiency cited, renewal inspection

• Six out of six participants interviewed stated they run laps or do 25 pushups if rules are not followed. The surveyor’s onsite survey and participant interviews on July 22, 2025

Deficiency cited, renewal inspection

• Participants did not have indoor areas of at least 40 square feet of floor space for quiet, reading, study, relaxing, and recreation. The youth have access to one living room downstairs that is approximately 200 square feet for 16 participants. There is one couch and two love seats in this room, which only allows for eight participants to sit at one time for movie watching and relaxation. Six out of six youth interviewed state that when in this room, half of them must sit on the floor. The surveyor’s onsite survey on July 22, 2025

Deficiency cited, renewal inspection

There are 2 bedrooms for the program participants, and both bedrooms have 7 program participants residing in them. Each bedroom has the capacity for eight program participants. The surveyor’s onsite survey and staff interviews on July 22,

Deficiency cited, renewal inspection

• Staff #4 states that the participant age range in both bedroom #1 and bedroom #2 ranges between 12-18, more than 3 years in age apart. The surveyor’s onsite survey and participant interviews on July 22, 2025

Deficiency cited, renewal inspection

• There is one bathroom with one toilet and one shower for 16 participants . Six out of six participants interviewed report that they are only allowed to shower three days a week

Deficiency cited, renewal inspection

• The provider does not have documentation of coliform bacteria testing completed during the last 12 months. The last documented testing was conducted on 05/03/2022. The surveyor’s onsite survey on July 22, 2025

Deficiency cited, renewal inspection

• The provider does not have documentation of an annual fire certification. The last documented certification is dated 05/16/2024. The surveyor’s onsite inspection on July 22, 2025.

Deficiency cited, renewal inspection

• The provider did not have documentation for the fire extinguishers located on the main floor and the lower level being inspected or tagged within the last 12 months. • The fire extinguisher on the lower level of the home was attached to the wall behind the couch, out of line of sight. The surveyor’s onsite inspection on July 22, 2025.

Deficiency cited, renewal inspection

• The provider did not provide documentation of monthly smoke detectors checks for the last 12 months. • The provider did not provide documentation of yearly replacement of smoke detector batteries in the last 12 months. The surveyor’s onsite survey on July 22, 2025.

Deficiency cited, renewal inspection

• The provider does not have documentation of quarterly audits of 1st aid kits for the home and transport vans for the last 12 months. The surveyor’s review of participant records on July 22, 2025.

Deficiency cited, renewal inspection

• The records for two out of two staff (Staff #1 and Staff #2) did not contain documentation of periodic performance evaluations. Repeat deficiency, 2023 plan of correction not followed. The Surveyor’s onsite survey on July 22, 2025.

Deficiency cited, renewal inspection

• The provider does not have documentation of participant satisfaction surveys completed in the last 12 months. The Surveyor’s onsite survey on July 22, 2025.

Deficiency cited, renewal inspection

• The provider does not have documentation of an annual report including improvements made as a result of the quality assessment activities specified in this rule. The Surveyor’s onsite survey on July 22, 2025.

Deficiency cited, renewal inspection

The program does not employ a registered nurse or licensed practical nurse to meet the needs of the program participants as outlined in the program description. The surveyor’s staff record review on July 22, 2025.

Deficiency cited, renewal inspection

• The record for one out of two staff (Staff #1) did not obtain current certification in de-escalation training.

Deficiency cited, renewal inspection

• The record for one out three participants (Participant #3) did not include documentation of a dental exam within 90 days of admission. Date of admit is 05/09/2024 and the exam was completed on 09/18/2024. Repeat deficiency, 2023 plan of correction not followed. The surveyor’s review of participant records on July 22, 2025.

Deficiency cited, renewal inspection

• The record for one out three participants (Participant #3) did not include documentation of a vision exam within 90 days of admission. Date of admit is 05/09/2024 and the exam was completed on 03/17/2025. Repeat deficiency, 2023 plan of correction not followed. The surveyor’s staff record review on July 22, 2025.

Deficiency cited, renewal inspection

• The records for two out of two staff (Staff #1 and Staff #2) did not contain documentation of training in proper medication procedures. The surveyor’s review of participant records on July 22, 2025.

Deficiency cited, renewal inspection

• The records for one out of three participants (Participant #1) did not contain documentation of medication errors. Lexapro 20 mg was not documented as administered on 6/22/2025, 6/25/2025, 6/26/2025, 6/29/2025, and 7/2/2025 and there are no medication error forms in the record. The surveyor’s review of participant records on July 22, 2025.

Deficiency cited, renewal inspection

• Participant # 1 ‘s record contained a physician order dated 06/24/2025 discontinuing Duloxetine, however it was

Deficiency cited, renewal inspection

• Six out of six participants interviewed stated that snacks are not provided and they are not allowed seconds at meals. The surveyor’s participant and staff interviews on July 22, 2025

Deficiency cited, renewal inspection

• Six out of six participants interviewed state that they frequently take time outs on the porch as directed by staff. Staff #3 and Staff #4 state that they do not document timeouts in participant files. The Surveyor’s review of staff records on July 22, 2025.

Deficiency cited, renewal inspection

• The records for one out of two staff (Staff #1) did not contain documentation of training in the proper protocol for all searches. The surveyor’s review of participant records and participant and staff interviews on July 22, 2025.

Deficiency cited, renewal inspection

• The records for three out of three participants (Participants #1, #2 and #3) did not contain documentation of money earned or received as gifts. Staff #3 stated that this is not recorded in participant files. The surveyor’s review of participant records and participant and staff interviews on July 22, 2025.

Deficiency cited, renewal inspection

• Six out of six participants interviewed stated that they are expected to spend their days outside working on the ranch. They are also expected to go to the ranches of other people in the community and staff members to work. This is not optional. Some of the work they do includes pulling weeds, bucking bales of hay, hauling wood, picking up sticks, neutering animals, etc. The participants and Staff #3 and Staff #4 state that the participants are not paid for this work, but are sometimes given popcorn, etc. for their work.

Deficiency cited, renewal inspection

• Six out of six participants interviewed stated that they do not have the opportunity to participate in recreational activities in the community. Playing basketball outside at the home is their only form of recreation.

Deficiency cited, renewal inspection

The surveyor’s review of 4 out of 15 current participants records on July 11, 2024. FINDINGS 1. Participant#2 did not have signed documentation of a completed ICPC prior to admit date. 2. Participant #4 did not have signed documentation of a completed ICPC prior to admit date. Participant #4 admit date was 1/15/24 and received ICPC back on 1/18/24/

Deficiency cited, renewal inspection

The surveyor's review of discharge records on 7/11/24.

Deficiency cited, renewal inspection

1) Surveyor had requested two discharge summaries from the provider for review. The program did not send surveyor any

Deficiency cited, renewal inspection

1. Participant#2 did not have signed documentation of a completed ICPC prior to admit date. 2. Participant #4 did not have signed documentation of a completed ICPC prior to admit date. Participant #4 admit date was 1/15/24 and received ICPC back on 1/18/24/

Deficiency cited, renewal inspection

1) Participant #1 and #3 case plan goals and objectives were not measurable and did not contain corresponding time frames. 2) Participant #2 and #4 case plan goals and objectives were not measurable. 3) Participant #1, #2, #3, and #4 case plans did not include discharge plan.

Deficiency cited, renewal inspection

The surveyor’s review of 4 out of 15 current participants records on July 11, 2024. FINDINGS 1) The program did not have written documentation that the following case plans were reviewed and signed by the participant’s parent. • Participant #1, plans dated 7/15/23, 10/23/23, and 1/30/24. • Participant #2, plans dated 8/12/23, 10/25/23, and 1/30/24. • Participant #3, plans dated 7/14/23, 10/23/23, 1/30/24, and 4/19/24. • Participant #4, plans dated 1/30/24 and 4/16/24.

Deficiency cited, renewal inspection

The surveyor’s review of 4 out of 15 current participants records on July 11, 2024. FINDINGS 1) Participant #1 case record did not contain written documentation of the clients rights statement being reviewed with parent at time of admission.

Deficiency cited, renewal inspection

1) Program records did not contain written documentation of fire drills being conducted quarterly per shift. Program records contained one drill conducted 9:00 am on 8/19/23.

Deficiency cited, renewal inspection

The surveyor’s review of 2 out of 6 current staff records on July 11, 2024. FINDINGS 1) Staff #1 personnel record did not contain current documentation of first aid and hands on CPR. 2) Staff #2 personnel record did not contain current documentation of crisis intervention and de-escalation training

Deficiency cited, renewal inspection

The surveyor’s review of 2 out of 6 current staff records on July 11, 2024. FINDINGS 1) Staff #1 personnel record did not contain written documentation of 20 hours of annual training.

Deficiency cited, renewal inspection

The surveyor’s review of 4 out of 15 current participants records and onsite review on July 11, 2024.

Deficiency cited, renewal inspection

FINDINGS 1)The program does not have documentation of differentiating between vocational learning and paid work for the participants. The participants do work in the community and other residents' home's that would not be in the normal work or tasks performed as part of living at the facility.

Deficiency cited, renewal inspection

The surveyor’s review of four current participant charts on May 03, 2023.

Deficiency cited, renewal inspection

1)Participant #3’s record did not contain written documentation of an immediate needs assessment being conducted at the time of admission. Participant #3’s admit date was 09/10/22 and the immediate needs assessment was completed 09/12/22. The surveyor’s review of one participant discharge file on May 3, 2023.

Deficiency cited, renewal inspection

1)The discharge summary for participant #5 was missing the following information: a. and name of parent/legal guardian; b. a written summary of services provided, including the program participant's participation and progress in the program; c. condition of the program participant at time of discharge; d. medical, dental, and psychiatric care received during placement; e. follow-up health care required; and

Deficiency cited, renewal inspection

1)Participant #2’s record did not contain documentation of dental examination being completed annually. Participant #2’s documentation of last dental examination was dated 01/05/22. The surveyor’s review of four current participant charts on May 03, 2023.

Deficiency cited, renewal inspection

1)Participant #2’s record did not contain documentation of vision examination being completed annually. Participant #2’s documentation of last dental examination was dated 03/29/22.

Deficiency cited, renewal inspection

The surveyor’s review of 4 out of 8 current participants records on May 16,2022. FINDINGS 1)Participant#1 did not have signed documentation of a completed ICPC prior to admit date. Participant #1 admit date was 7/10/21 and received ICPC back on 07/28/21. Repeat Deficiency Plan of Correction from 1/19/21 not followed.

Deficiency cited, renewal inspection

The surveyor’s review of 4 out of 8 current participants records on May 16,2022.

Deficiency cited, renewal inspection

1)Participant#1 and Participant #3 case plan reviews and updates identified by the program showed no review or update to the participant case plan every 90 days as required. Repeat Deficiency Plan of Correction from 1/19/21 not followed. THE INTENT OF THIS RULE HAS NOT BEEN MET AS EVIDENCED PROGRAMS: CASE PLAN

Deficiency cited, renewal inspection

1)Participant#1 did not have signed documentation of a completed ICPC prior to admit date. Participant #1 admit date was 7/10/21 and received ICPC back on 07/28/21. Repeat Deficiency Plan of Correction from 1/19/21 not followed.

Deficiency cited, renewal inspection

1) The program did not have written documentation that the following case plan were reviewed and signed by the participant: .Participant#1, plans dated 7/27/21, 9/30/21,1/27/22 and 4/30/22; •Participant #2, plans dated 1/28/21,4/16/21,7/27/21,9/30/21,1/26/22 and 4/30/22; and •Participant #3, plans dated 1/28/21, 4/17/21, 7/27/21, 1/26/22 and 5/1/22. 2) Participant #3 had no documentation any of the signed case plan being provided to parent/legal guardian. Repeat Deficiency Plan of Correction from 1/19/21 not followed.

Deficiency cited, renewal inspection

The surveyor’s review of 4 out of 9 current staff records on May 16, 2022.

Deficiency cited, renewal inspection

1)Staff #1 record did not have a complete background check completed prior to working at the facility. Staff #1’s hire date was 02/21/21 and background check results received on 4/1/21.

Deficiency cited, renewal inspection

The Surveyor’s onsite inspection on May 16, 2022

Deficiency cited, renewal inspection

1)The interior of the oven in the kitchen had a buildup of food particles on the stove door and bottom of oven.

Deficiency cited, complaint inspection

The surveyor’s review of program documentation and interview with the program administrator on April 20, 2021.

Deficiency cited, follow up inspection

The surveyor’s review of five participants records on November 30, 2020.

Deficiency cited, follow up inspection

1) Participant #2’s record did not include documentation of an initial assessment completed at the time of admission.

Deficiency cited, follow up inspection

1) Participant #1, #2, #3, and #4’s records did not include required information for compliance with the ICPC placement process for out of state placed participants. Participants ICPC information reviewed did not include the sending state’s ICPC administrators or receiving states ICPC administrators’ signature. These two signatures identified are required in order to document both the sending and receiving state have approved the placement of the participant to the program. REPEAT DEFICIENCY Plan of correction accepted 7/29/20 not followed.

Deficiency cited, renewal inspection

The surveyor’s review of eight participants records on June 3, 2020.

Deficiency cited, renewal inspection

1) Participant #6’s records did not include required information for compliance with the ICPC placement process for out of state placed participants. Participants ICPC information reviewed did not include the sending state’s ICPC administrators or receiving states ICPC administrators’ signature. These two signatures identified are required in order to document both the sending and receiving state have approved the placement of the participant to the program.

Deficiency cited, renewal inspection

1) Participant #1, #2, #3, #4, #5, #6, #7, and #8’s case plans did not include the following requirements: •the program participant’s physical and medical needs; •measurable goals and objectives and corresponding time frames; and •discharge plans and estimated discharge date.

Deficiency cited, renewal inspection

1) Participant #1, #2, #3, #4, #5, #6, #7 and #8’s case plans did not include written documentation that the participant as well as the parent/legal guardian participated in the development and updating of the case plan.

Deficiency cited, renewal inspection

1) Staff #1’s and Staff #6 file did not have documentation of a NCIC fingerprint background check, a name based criminal background check, DPHHS child protective background check, and the Montana and National Sexual and Violent offender registry check completed prior to employment. Staff #1’s date of hire was 6/1/16 and Staff #6 date of hire was 2/18/18. The department has requested all background check paperwork be completed and submitted on all staff hired prior to the implementation date of the rule if programs did not have the results on file.

Deficiency cited, renewal inspection

1) Staff #1 and Staff #3’s records did not contain documentation of completion of the programs de-escalation and methods of managing program participants as described in the program’s polices. 2) Staff #6 de-escalation training expired 8/19. 3) Staff #4 and Staff #5’s record did not contain documentation of completion of training on first aid and hands on CPR.

Deficiency cited, renewal inspection

1) Participant #1, #2, #3, #5, #6 and Participant #7’S record did not contain documentation of a physical examination within a year prior to placement or within 30 days after admission.

Deficiency cited, renewal inspection

(1) Participant #1, #2, #3, #5, #7 and #8’s record did not contain documentation of a dental examination within a year prior to placement or within 90 days after admission.

Deficiency cited, renewal inspection

(1) Participant #1, #3, #5, #7 and #8’s records did not contain documentation of a vision examination within a year prior to placement or within 90 days after admission.

Deficiency cited, renewal inspection

1) Participant #1, #2, #3, #4, #5, #6’s, 7’s and 8’s records did not have document of time-outs conducted. The program time-outs are referenced as reflection time, grabbing a tree or cool downs.