Shiloh Treatment Center

Risk level: Medium High : 748.303(a)(2)(A) - AP Serious Incdt-Report to Licensing no later than 24 hours after injury/illness that warrants treatment by a medical professional or hospitalization

A child was seen on 6/16/2026 by a medical professional for injuries sustain to their right hand & left thumb after a physical altercation. This incident was not reported to Licensing until 6/22/2026.

Risk level: High : 748.2801(2)(B) - EBI Time Limits-Prone or supine personal restraint hold may not exceed one minute.

An operational staff member exceeded the required time limit when utilizing prone and supine restraints as required in Minimum Standards.

Risk level: High : 748.2605(a)(2) - Personal Restraints Prohibited-Restraints that obstruct child's airway

An operational staff member placed a child in a prone and supine position during a restraint on a couch. The staff member failed to discontinue the restraint when the child verbally indicated that he was having difficulty with breathing.

Risk level: High : 748.2601(a) - Personal Restraint Monitor-Qualified caregiver monitors child for signs of physical distress & ensures ample respiration, circulation, well-being

Two caregivers were involved in a physical restraint of a child, and staff members failed to ensure that signs of distress were monitored appropriately during the restraint.

Risk level: Medium High : 748.2455(a)(1) - Emergency Behavior Intervention-Before using EBI, the caregiver must attempt less restrictive interventions that prove to be ineffective

Staff did not attempt de-escalation or a lesser intervention prior to utilizing a restraint.

Risk level: Medium : 748.311 - Serious Incident Documentation-Documented in written report

The operation failed to complete an incident report related to a non-routine incident concerning aggression and an EBI incident that occurred between a youth and two operational staff members.

Risk level: Medium High : 748.2553(2)(C) - EBI Release-Child released from personal restraint as soon as child is not a danger to self or others

An operational staff member failed to release a youth from a physical hold, when the youth was no longer displaying behavior that exhibited that the child was a danger to himself or others.

Risk level: High : 748.2307(1) - Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment

An operational staff member responded to a child in a physically aggressive manner by pushing the child as a means of discipline prior to conducting an inappropriate restraint.

Risk level: Medium : 748.126(b) - All employees and caregivers must be aware of and follow your policies and procedures

Two operational staff members completed an EBI transport for a child by dragging the child across the living room area of the home.

Risk level: Medium : 748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records

The details documented in the operational Emergency Personal Restraint Report are inconsistent with the events observed in the operational video recording.

Risk level: Medium : 748.453(a)(1) - Unauthorized Absence - Annual summary log must include name, age, gender, date of admission

The unauthorized absence log does not have the required components such as the child's age, gender or date of admission.

Risk level: Medium : 748.363(2) - Personnel records-Include documentation showing that the person meets minimum age and qualifications for the position

During a monitoring inspection a staff record reviewed did not contain a copy of a high school diploma to indicate that they qualify for their position at the operation.

Risk level: Medium : 748.363(4) - Personnel records-Personnel records-Include current job description.

During a monitoring inspection staff files reviewed did not include the personnel's job description.

Risk level: Medium : 748.2951(d) - Evaluation-Results of each overall annual evaluation made available to Licensing for review.

The operation did not have an overall annual EBI evaluation for review.

Risk level: Medium Low : 748.751(b)(2) - Pre-Employment Screening-You must document the results of any contact with an applicant's previous employers in the personnel file.

During a monitoring inspection, it was found that one out of four staff files reviewed there was no documentation of any contact with the applicant's previous employers.

Risk level: High : 748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being

A 13-year-old child with documented high-risk behaviors was not adequately supervised, and proper de-escalation techniques were not utilized by direct care staff.

Risk level: High : 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation

During a DFPS investigation, it was found a 13-year-old child in care was neglectfully supervised when a caregiver repeatedly failed to de-escalate her.

Risk level: High : 748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work.

A caregiver aggressively shoved a 13-year-old child in care on three occasions during a struggle over the caregiver's personal items.

Risk level: Medium : 748.1103(d) - Informing child of rights-Person being informed must sign statement indicating he read and understands the rights-signed copy filed in child's record

The review of two children records found that both children who are over the age of 6 did not sign the Child's Rights statement acknowledging they have read and understood the listed rights.

Risk level: Medium High : 748.2455(a)(2) - Emergency Behavior Intervention-Basis for EBI is an emergency situation or to administer medication

The review of two restraint reports showed the basis for EBI was not an emergency situation.

Risk level: Medium Low : 748.1381(2) - Service Plan Review-If child receiving treatment services for ED, ASD, or PMN, review at least 90 days from date of last service plan

One of the children records reviewed found the last service plan review was completed on February 20, 2025.

Risk level: Medium : 748.1337(b)(1)(A)(vi)(I) - Initial Service Plan - Normalcy - Include plans for social, extracurricular, recreation, and leisure activities

The review of two children records found normalcy was not addressed in the children's service plan.

Risk level: Medium : 748.861(b)(3) - Pre-Service Training - Supervised experience must be documented in personnel record

One staff record reviewed is missing documentation of supervised experience training.

Risk level: Medium Low : 748.751(b)(2) - Pre-Employment Screening-You must document the results of any contact with an applicant's previous employers in the personnel file.

Two staff records reviewed were missing documentation of the results of any contact with an applicant's previous employers. Two other records did not include results of contact from all previous employers prior to application date.

Risk level: Medium High : 748.1205(a)(7) - Admission Documentation-Includes child's immunization record

Immunization record was missing from one of the children's records reviewed.