North Homes Boys Program

Violation cited by DHS

The license holder’s policies and practices of trauma-informed care did not meet requirements in the following ways: a. The program’s designated spaces available to youth for engaging in sensory and self-soothing activities were not described in policy; b. The program staff did not ensure the designated spaces were available to the youth to use when needed; and c. Policies did not include that the program prohibits the use of aversive consequences for a youth’s violation of program rules or for any other reason. Correction Action Ordered: Immediately and on an ongoing basis, the license holder must ensure trauma-informed care policies and practices meet all applicable requirements. Within 30 days receipt of this order, submit revised policies on trauma-informed care, as identified above, to demonstrate compliance.

Violation cited by DHS

The license holder’s service delivery plan did not meet requirements. The program’s service delivery plan did not include and describe how the license holder: a. Collaborates with the responsible social services agency and other appropriate parties to implement the youth’s out of home placement plan and the youth’s short-term and long-term mental health and behavioral health goals in the assessment; b. Facilitates the participation of a youth’s family members in the youth’s treatment program; c. Contacts and facilitates outreach to each youth’s family members, including the youth’s siblings, and documenting the outreach in the youth’s file, including the contact method and each family member’s contact information; and d. Documents in the youth’s file how the program integrates family members into the treatment process, including after the youth’s discharge, and how the program maintains the youth’s connections to the youth’s siblings. Correction Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the program’s service delivery plan meets all applicable requirements. Within 30 days receipt of this order, submit a service delivery plan that meets requirements to demonstrate compliance. Personnel Files Personnel files reviewed are identified in the following manner: · Personnel files numbered 1 through 5: Boys Program and TNT

Violation cited by DHS

Five of five personnel files reviewed for requirements governing training did not meet requirements in the following ways: a. There was no documentation to demonstrate that prior to direct contact with a youth, a staff was oriented to: 1) Concepts of trauma informed care and how to provide services according to these concepts in calendar year 2022 (personnel files numbered 1 through 3); and 2) Impacts of culture, race, gender, and sexual orientation on an individual youth’s behavioral health and experiences of trauma in calendar year 2022 (personnel files numbered 1 through 5); and b. There was no documentation to demonstrate staff were trained annually to: 1) Concepts of trauma informed care and how to provide services according to these concepts in calendar year 2022 (personnel file numbered 1); and 2) Impacts of culture, race, gender, and sexual orientation on an individual youth’s behavioral health and experiences of trauma in calendar year 2022 (personnel files numbered 1 and 5).

Violation cited by DHS

Five of five youth files reviewed for requirements governing trauma-informed care did not meet requirements. Documentation did not demonstrate: a. Whether the youth participated in reviewing and developing their individual treatment or service plan (youth files 1 and 5); b. Whether the license holder adjusted services for the youth to address any additional needs of the youth (youth files numbered 1 through 3); c. If an assessment was completed to determine if the youth was in need of trauma-specific treatment interventions (youth files numbered 1 through 5); d. How the license holder recognized the impact of trauma on the youth when determining the youth’s service needs and providing services to the youth (youth files numbered 1 through 5); and e. In the youth’s treatment plan, how the program would provide trauma-specific treatment interventions to the youth to target the youth’s specific trauma-related symptoms (youth files numbered 1 through 5).

Violation cited by DHS

Five of five youth files reviewed for requirements governing services in qualified residential treatment programs did not meet requirements. Documentation did not demonstrate the license holder: a. Collaborated with the responsible social services agency and other appropriate parties to implement the youth’s out-of-home placement plan and the youth’s short-term and long-term mental health and behavioral health goals in the assessment (youth files numbered 1, 2, and 3); b. Completed treatment plan reviews for July 2023 (youth file numbered 2) and February, March, April, and June 2022, and January and March 2023 (youth file numbered 5); c. Facilitated the participation of a youth’s family members in the youth’s treatment program that was consistent with the youth’s best interests and according to the youth’s out-of-home placement plan (youth files numbered 2 through 5); d. Contacted and facilitated outreach to each youth’s family members, including the youth’s siblings, and documented the contact method and contact’s information in the youth’s file (youth files numbered 1 through 5); e. Maintained a record of contact information for all known biological family members and fictive kin of the youth (youth files numbered 1 through 5); f. Integrated family members into the youth’s treatment process, including after the youth’s discharge from the program, and the youth’s connections to their siblings (youth files 1 through 5); g. Provided discharge planning and family-based ...

Maltreatment Determined as to neglect of five alleged victims by a staff person. Substantiated as to neglect ...

Information from AV1-AV6, VA1, P1, and P2, was consistent that on March 22, 2025, the SP took AV1-AV5, and VA1 on a walk and when they returned each appeared to be under the influence of a substance with the exception of AV5. AV1-AV5, and VA1 each stated that when they were on the walk the SP allowed them to use the SP’s vape/carts that contained THC and/or nicotine. In addition, information from AV1-AV6, VA1, and VA2 was consistent that there were multiple other times at the facility and in the van when the SP allowed the youth to use the SP’s vape/cart that contained nicotine/THC. The SP denied allowing the youth to use his/her vapes/carts with marijuana. Although during the interview the SP denied giving the youth his/her vape/cart with nicotine, with the exception of one occasion when s/he allowed VA3 to use his/her personal nicotine vape, during the Internal Review, the SP stated that s/he allowed the youth to use his/her vape with nicotine. The SP stated that the youth obtained the vapes/carts with nicotine and/or marijuana from school or work. The SP stated that initially s/he did not allow the youth to use their own vapes/carts but eventually allowed them to do so while on walks, during outings, and while at the facility, and did not do anything to stop the youth from doing so. In addition, the SP stated that it “got to a point” where s/he stopped writing up the youth for having nicotine and THC vapes because s/he “did not know what to write anymore.” Although the SP ...