South Bluff Teaching Family Home

Violation established, special investigation : CCI Rule 400.4109 Program statement

The facility is found in noncompliance as per interviews with Youth B, Youth C, and Staff 2, all reported Staff 1 was speeding on the way to take the youth to school. Youth B reported Staff 1 always speeds. Staff 2 reported Staff 1 was on his cellphone to change songs while driving.

Repeat violation established, special investigation : CCI Rule 400.4159 Youth restraint; pregnant youth; reduction, prevention; prohibited restraints; elimination of restraints.

The facility is found in noncompliance as Staff 1 placed Youth B in three separate restraints not using the correct Handle with Care techniques per interviews and review of video footage. TECHNICAL ASSISTANCE: Technical assistance was offered to retrained staff on Handle with Care and the facility review the videos with staff as a training tool to discuss with the number of staff present, and best restraint technique to utilize in situations.

Violation established, special investigation : CCI Rule 400.4163 Health status assessment; notification; debriefing; reporting.

The facility is found in noncompliance as per review of video, Youth B was placed in three separate restraints and the facility did not complete incident reports on the form prescribed by the department for each of the restraints. The facility completed one incident report for Youth B being escorted by Staff 1 three times during the incident. TECHNICAL ASSISTANCE: Technical assistance was offered to educate all staff on PA 116 definition of an escort and the definition of a personal restraint per CCI licensing rules definition to ensure staff are documenting restraints per licensing rules. Also, the supervisor reviewing incident reports in MiSACWIS, could compare the incident report to the video footage to ensure accurate coding and description of the events is narrated correctly in the incident report. Additionally, additional training for staff to document details of incident reports.

Repeat violation established, special investigation : R 400.4126 Sufficiency of staff

The facility is found in noncompliance as staff reported they did not feel safe intervening to attempt to take the cell phones and the laptop computer away from the youth as staff felt Youth A and Youth B would assault them. Staff were aware that the youth were having inappropriate sexual conversations, Youth A was found to be topless on a video chat with an unknown male, Youth A and Youth B were engaging an unknown adult male to masturbate for them over video, Youth A and Youth B were planning to AWOLP from the facility and Youth A and Youth B’s safety plans were not being followed due to staff not feeling safe to intervene. Staff did not let Youth A and Youth B back into the house as the door locked after they exited the house due to staff feeling unsafe. Supervisors and Administrators were made aware of these concerns and failed to provide adequate direction to staff to intervene. TECHNICAL ASSISTANCE: The agency needs to update the Youth Truancy Policy to reflect law enforcement is contacted immediately when staff lose sight of youth.

Violation established, special investigation : R 400.4127 Staff to resident ratio

The facility is found in noncompliance as Youth A and Youth B were in Youth A’s bedroom for two and a half hours with the door closed and Staff 1 reported she did not complete eyes-on checks of the youth in variable intervals not to exceed 15 minutes.

Violation established, special investigation : R 400.4108 Financing and audit

After review of the third-party audit as well as the report from the Bureau of Audit it is determined that Teaching Family Homes currently is in a declining financial condition.

Violation established, special investigation : Rule 2 Prohibition of Prone Restraint; Procedures Involving

The facility did not enter any physical restraints in MiSACWIS for several months, evidenced by those responsible, Director 1 and Staff 6, having not used MiSACWIS for at least 60 days, losing access and not requesting access back timely or appropriately. While the emergency rules have expired 7/16/2021, this requirement has been built into your contract; therefore, requiring corrective action.

Violation established, special investigation : FOM 722-02B GUIDANCE FOR RESTRAINTS IN CHILD CARING

The facility is not sending the incident reports to DCWL as required by policy.

Violation established, special investigation : R 400.4126 Sufficiency of staff

Based on the video recording and interviews, clearly South Bluff and Indian River were combined on March 20, 2021, which was in violation of the above rule, because there were only three staff for the two CCI programs. Additionally, based on the video, the staff were not closely observing these youth as they laid on couches and a bean bag chair covered with blankets, with the couches positioned in such a way the staff could not observe what was going on.

Violation established, special investigation : R 400.4116 Chief administrator; responsibilities

Based on the video and interviews South Bluff and Indian River were combined on March 20, 2021, in non-compliance with the safety plan that was signed by Director 1, the chief administrator, on March 8, 2021.

Repeat violation established, special investigation : R 400.4109 Program statement

Investigation 1: Staff 1 and Staff 4 reported that an incident report was not completed by the agency. A review of the agency policy regarding incidents requires that the agency complete an incident report. The agency failed to follow their policy as an incident report was not completed. Investigation 2: The safety plan for Resident A was initiated on August 28, 2020, 15 days after the incident. The safety plan for Resident A was developed late, which did not ensure her safety for a period of 15 days.

Repeat violation established, special investigation : R 400.4109 Program Statement

The agency policy for Room Checks specifically addresses the arming and disarming of alarms. However, according to staff and the Director of Maintenance, the alarm system does not work and has not worked in about 8 months.

Violation established, special investigation : R 400.4109 Program statement

Evidence is insufficient to establish that Staff 1 had an inappropriate photo on his cell phone which Resident A viewed. Staff 1 denied that he had a picture of a penis on his cell phone. Resident A reported that there was such a photo but that she could not see the picture clearly. A rule violation was established as Staff 1 allowed Resident A to use his cell phone which is prohibited by agency policy. Staff 1 acknowledged that he allowed Resident A to use his cell phone.

Violation established, special investigation : R 400.4128 Initial staff orientation and ongoing staff training

Teaching Family Homes – South Bluff administration failed to obtain approval in writing for the training curriculum. The facility changed the curriculum and did not make the request to the assigned consultant, therefore did not have approval in writing from November 2, 2018 until May 7, 2020.

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

The emails from the Complainant to the agency Social Service Worker and the Physician Assistant document that the agency was notified upon intake of Resident A’s clozapine medication as well as the medically ordered blood draws. Intake packet information also established that the agency was aware of Resident A’s medical needs upon her placement into the program. Medication logs established that Resident A was not receiving her clozapine medication on a daily basis as prescribed. There was a document that indicates that only 1 blood draw was conducted during her month long stay at the program. The Chief Administrator acknowledged that Resident A was without her clozapine medication for about 2 weeks and only 1 blood draw was conducted. The agency failed to provide medically ordered routine medical care and the dispensing of a prescribed medication.