Yellowstone Boys and Girls Ranch

Deficiency cited, renewal inspection

The surveyor’s review of 3 staff records on August 21, 2025. FINDINGS 1)Staff #2’s record did not contain written documentation of completing CPR/ first aid training.

Deficiency cited, renewal inspection

1)Staff #2’s record did not contain written documentation of completing CPR/ first aid training.

Deficiency cited, complaint inspection, repeat deficiency

The intent of the rule is not met as evidenced by: The surveyor’s review of youth records on 05/23/2025.

Deficiency cited, complaint inspection, repeat deficiency

One out of one youth (Youth #1) did not receive 75 minutes of therapy during the below weeks. Date of admit is 02/27/2025. • 03/23/2025-03/29/2025: Individual therapy only for 55 minutes • 04/06/2025-04/12/2025: Individual therapy only for 50 minutes • 04/13/2025-04/19/2025: no therapy Repeat deficiency, plan of correction not followed. The intent of the rule is not met as evidenced by: The surveyor’s review of youth records on 05/23/2025.

Deficiency cited, complaint inspection, repeat deficiency

One out of one youth (Youth #1) did not receive family therapy during his placement. Date of admit is 02/27/2025 and date of discharge is 04/21/2025. Both parents have custody and are involved in his care. Notes state that family therapy did not occur for the following reasons. • “Family sessions will begin when new therapist starts.” • “Family therapy did not occur due to staffing. The agency will work to identify a therapist with an opening.” Repeat deficiency, plan of correction not followed. The intent of the rule is not met as evidenced by: The surveyor’s review of youth records on 05/23/2025.

Deficiency cited, complaint inspection, repeat deficiency

1. The initial treatment plan for one out of one youth (Youth #1) was not developed within 10 business days of admission. Date of admit is 02/27/2025 and the plan was completed on 03/21/2025. 2. The treatment plans dated 02/27/2025 and 03/27/2025 for one out of one youth (Youth #1) did not contain (a, g, h, I and k). Repeat deficiency, plan of correction not followed. The intent of the rule is not met as evidenced by: The surveyor’s review of youth records on 05/23/2025.

Deficiency cited, complaint inspection, repeat deficiency

The treatment plan meetings for one out of one youth (Youth #1) were not conducted face-to-face with the youth, document the input of the youth and parent/legal guardian, and include all treatment team members. There is no documentation for the meetings and no signatures on the plans other than the mental health professional. Repeat deficiency, plan of correction not followed. The intent of the rule is not met as evidenced by: The surveyor’s review of youth records on 05/23/2025.

Deficiency cited, complaint inspection, repeat deficiency

The record for one out of one youth (Youth #1) did not contain documentation of notification to all treatment team members of the time and place of the treatment plan reviews dated 02/27/2025 and 03/27/2025. Repeat deficiency, plan of correction not followed. The intent of the rule is not met as evidenced by: The surveyor’s review of youth records on 05/23/2025.

Deficiency cited, complaint inspection, repeat deficiency

The record for one out of one youth (Youth #1) did not contain documentation that the youth, all direct care staff and the mental health professional involved in the care of the youth read and signed off on treatment plans within seven days of its development and update. • 02/27/2025: mental health professional signature only on 03/21/2025 • 03/27/2025: mental health professional signature only on 05/07/2025 Repeat deficiency, plan of correction not followed. The intent of the rule is not met as evidenced by: The surveyor’s review of youth records on 05/23/2025.

Deficiency cited, complaint inspection, repeat deficiency

The record for one out of one youth (Youth #1) did not contain documentation that treatment plans dated 02/27/2025 and 03/27/2025 were provided to the youth's parent/legal guardian within ten days of the plan's development or update. Repeat deficiency, plan of correction not followed.

Deficiency cited, provisional status inspection

The intent of the rule is not met as evidenced by: The surveyor’s review of youth records on 02/26/2025.

Deficiency cited, provisional status inspection

The files for two out of two youth (Youth #1 and #2) did not contain an immediate needs assessment and assigned responsibilities. The intent of the rule is not met as evidenced by: The surveyor’s review of staff records on 03/04/2025.

Deficiency cited, provisional status inspection

The file for one out of two staff (Staff #1) did not contain documentation of orientation training in trauma informed care. Date of hire is 01/14/2025 and the training has not been completed to date. The staff member is currently being counted in the staffing ratio. The intent of the rule is not met as evidenced by: The surveyor’s review of youth records on 02/26/2025.

Deficiency cited, provisional status inspection

The files for two out of two youth (Youth #1 and #2) did not contain documentation of medication errors, results of errors, and any effects observed. • Youth #1: youth was not administered lamotrigine, methylphenidate and/or clonidine on 02/08/2025, 02/14/2025, and 02/15/2025. • Youth #2: youth was not administered hydroxyzine and/or risperidone on 02/7/2025, 02/19/2025, 02/20/2025, 02/21/2025 and 02/25/2025. The intent of the rule is not met as evidenced by: The surveyor’s onsite inspection on 02/26/2025.

Deficiency cited, provisional status inspection

1. The inside of the fridge has missing pieces/shelves and pieces that are taped together. 2. The baseboard heating units are broken and missing pieces, exposing sharp metal. The intent of the rule is not met as evidenced by: The surveyor’s review of youth records on 02/26/2025.

Deficiency cited, provisional status inspection

The file for one out of two youth (Youth #1) did not contain documentation of a clinical assessment within ten business days (Monday through Friday) of admission, or a clinical assessment completed within the last three months prior to admission. Date if admit is 11/25/2024 and the assessment was completed on 03/11/2024. The intent of the rule is not met as evidenced by: The surveyor’s review of youth records on 02/26/2025.

Deficiency cited, provisional status inspection

The 01/13/2025 treatment plans for two out of two youth (Youth #1 and #2) did not contain (a, g, h, i and k). The intent of the rule is not met as evidenced by: The surveyor’s review of youth records on 02/26/2025.

Deficiency cited, provisional status inspection

The 01/13/2025 treatment plan meetings for two out of two youth (Youth #1 and #2) were not conducted face-to-face with the youth and did not document the input of the youth (over the age of 5), parent/legal guardian, and placing agency. The intent of the rule is not met as evidenced by: The surveyor’s review of youth records on 02/26/2025.

Deficiency cited, provisional status inspection

The files for two out of two youth (Youth #1 and #2) did not contain documentation of notification to all treatment team members of the time and place of the treatment plan review. The intent of the rule is not met as evidenced by: The surveyor’s review of youth records on 02/26/2025.

Deficiency cited, provisional status inspection

The files for two out of two youth (Youth #1 and #2) did not contain documentation that the youth and all direct care staff read and signed off on treatment plans within seven days of its development and update. • Youth #1: 11/25/2024, 12/23/2024 and 01/13/2025 • Youth #2: 11/04/2024, 12/19/2024 and 01/13/2025 The intent of the rule is not met as evidenced by: The surveyor’s review of youth records on 02/26/2025.

Deficiency cited, provisional status inspection

The files for two out of two youth (Youth #1 and #2) did not contain documentation that treatment plans were provided to the youth's parent/legal guardian within ten days of the plan's development or update.

Deficiency cited, provisional status inspection

The intent of the rule is not met as evidenced by: The surveyor’s review of youth records on 02/26/2025.

Deficiency cited, provisional status inspection

The files for two out of two youth (Youth #1 and #2) did not contain an immediate needs assessment and assigned responsibilities. The intent of the rule is not met as evidenced by: The surveyor’s review of youth records on 02/26/2025.

Deficiency cited, provisional status inspection

The files for two out of two youth (Youth #1 and #2) did not contain documentation of all outreach efforts to identified family, to build a positive network to support the wellbeing of the youth. Documentation must include: (i) a minimum of two attempts to contact all identified family; and (ii) results of each contact. The intent of the rule is not met as evidenced by: The surveyor’s review of staff records on 03/04/2025.

Deficiency cited, provisional status inspection

The file for one out of two staff (Staff #2) did not contain current certification in Mandt. The intent of the rule is not met as evidenced by: The surveyor’s review of youth records on 02/26/2025.

Deficiency cited, provisional status inspection

The files for two out of two youth (Youth #1 and #2) did not contain documentation of medication errors, results of errors, and any effects observed. • Youth #1: youth was not administered fluoxetine and/or melatonin on 02/09/2025, 02/16/2025, 02/18/2025 and 02/19/2025. • Youth #2: youth was not administered Adderall XL on 02/5/2025, 02/09/2025, 02/13/2025, 02/14/2025 and 02/16/2025. The intent of the rule is not met as evidenced by: The surveyor’s onsite inspection on 02/26/2025.

Deficiency cited, provisional status inspection

The carpet throughout the homes is dirty and heavily stained. The intent of the rule is not met as evidenced by: The surveyor’s review of youth records on 02/26/2025.

Deficiency cited, provisional status inspection

The file for one out of two youth (Youth #2) did not contain documentation of a clinical assessment within ten business days (Monday through Friday) of admission, or a clinical assessment completed within the last three months prior to admission. Date if admit is 11/21/2024 and the assessment was completed on 07/10/2024. The intent of the rule is not met as evidenced by: The surveyor’s review of youth records on 02/26/2025.

Deficiency cited, provisional status inspection

Two out of two youth (Youth #1 and #2) did not receive 75 minutes of therapy during the below weeks. Dates of admit are 11/27/2024 and 11/21/2024 respectively. • 12/1/2024-12/07/2024 • 12/08/2024-12/14/2024 • 12/22/2024--12/28/2024 • 12/29/2024-01/04/2025 • 01/05/2025-01/11/2025 • 01/12/2025-01/18/2025 • 01/19/2025-01/25/2025 The intent of the rule is not met as evidenced by: The surveyor’s review of youth records on 02/26/2025.

Deficiency cited, provisional status inspection

1. Two out of two youth (Youth #1 and #2) did not receive 50 minutes of individual therapy during the below weeks. Dates of admit are 11/27/2024 and 11/21/2024 respectively. • 12/22/2024--12/28/2024 • 01/05/2025-01/11/2025 • 01/12/2025-01/18/2025 • 01/19/2025-01/25/2025 (Youth #1 only) 2. One out of two youth (Youth #2) has not received family therapy since admit. Date of admit is 11/21/2024. Both parents have custody and are involved in his care. The intent of the rule is not met as evidenced by: The surveyor’s review of youth records on 02/26/2025.

Deficiency cited, provisional status inspection

The treatment plans for two out of two youth (Youth #1 and #2) did not contain (a, g, h, i and k). • Youth #1: 11/26/2024, 12/11/2024 and 01/13/2025 • Youth #2: 11/20/2024, 12/05/2024 and 01/13/2025 The intent of the rule is not met as evidenced by: The surveyor’s review of youth records on 02/26/2025.

Deficiency cited, provisional status inspection

The treatment plan meetings for two out of two youth (Youth #1 and #2) were not conducted face-to-face with the youth and did not document the input of the youth (over the age of 5), parent/legal guardian, and placing agency. • Youth #1: 11/26/2024, 12/11/2024 and 01/13/2025 • Youth #2: 11/20/2024, 12/05/2024 and 01/13/2025 The intent of the rule is not met as evidenced by: The surveyor’s review of youth records on 02/26/2025.

Deficiency cited, provisional status inspection

The files for two out of two youth (Youth #1 and #2) did not contain documentation of notification to all treatment team members of the time and place of the treatment plan review. The intent of the rule is not met as evidenced by: The surveyor’s review of youth records on 02/26/2025.

Deficiency cited, provisional status inspection

The files for two out of two youth (Youth #1 and #2) did not contain documentation that the youth, all direct care staff and the mental health professional involved in the care of the youth read and signed off on treatment plans within seven days of its development and update. • Youth #1: 11/26/2024, 12/11/2024 and 01/13/2025 • Youth #2: 11/20/2024, 12/05/2024 and 01/13/2025 The intent of the rule is not met as evidenced by: The surveyor’s review of youth records on 02/26/2025.

Deficiency cited, provisional status inspection

The files for two out of two youth (Youth #1 and #2) did not contain documentation that treatment plans were provided to the youth's parent/legal guardian within ten days of the plan's development or update.

Deficiency cited, provisional status inspection

The intent of the rule is not met as evidenced by: The surveyor’s review of staff records on 03/04/2025.

Deficiency cited, provisional status inspection

The files for two out of two staff (Staff #1 and #2) did not contain documentation of orientation training as listed below. Dates of hire are 01/14/2025 and 09/30/2024 and the training has not been completed to date. The staff members are currently being counted in the staffing ratio. • Staff #1 (a, f, g and h) • Staff #2 (c-i) The intent of the rule is not met as evidenced by: The surveyor’s review of staff records on 03/04/2025.

Deficiency cited, provisional status inspection

The files for two out of two staff (Staff #1 and #2) did not contain documentation of orientation training in trauma informed care. Dates of hire are 01/14/2025 and 09/30/2024 and the training has not been completed to date. The staff members are currently being counted in the staffing ratio.

Deficiency cited, complaint inspection

Intent of the rule is not met as evidenced by: The surveyor’s review of records.

Deficiency cited, complaint inspection

Staff #2, #3, #4, #5, #6, #7, #8, #9, #10 and #11 failed to report possible abuse of Youth #1 promptly to Child Protective Services. The initial report alleging possible abuse of Youth #1 was made on 11/25/2024. Additional reports were made on 11/28/2024, 11/29/2024 and 12/01/2024. The incident was not reported to Child Protective Services until 12/02/2024. • On 11/25/2024, Staff #10 sent an email to Staff #7, Staff #5 and Staff #2 to report another youth reported Staff #1 and Youth #1 had been “flirting.” • On 11/28/2024, Staff #8 sent an email to Staff #4 and Staff #6 reporting two youth reported Staff #1 had typed “you’re cute” into his phone and showed it to Youth #1, but did not know the date this occurred. Staff #4 forwarded this email to Staff #2 and Staff #3. • On 11/29/2024, Youth #1 made a report to Staff #9 that Staff #1 had told her that after he had inventoried her underwear/thongs and clothes that he was fantasizing about her in them. Staff #9 discussed the report with his co-worker on shift, Staff #11 and contacted Staff #4. Staff #9 created a written Major Incident Report for this incident on 11/29/2024. Staff #11 sent a follow-up email to Staff #4 on 11/30/2024. Staff #4 signed off on the written MIR on 11/30/2024. • On 12/1/2024, Youth #1’s sister sent an email to Staff #6 of screen shots of Youth #1’s Snapchat messages from Staff #1. Messages included “you are fine af”, “Just thinking about you beautiful Youre pretty dam amazing”, “Just thinking about ya ...

Deficiency cited, complaint inspection

The provider failed to initiate an investigation of allegations of abuse by the professional person in charge of the facility as soon as possible after the initial report of the incident, but not later than by the end of the next business day. The initial report alleging possible abuse of Youth #1 was made on 11/25/2024. Additional reports were made on 11/28/2024, 11/29/2024 and 12/01/2024. An internal investigation was not initiated until 12/02/2024. • On 11/25/2024, Staff #10 sent an email to Staff #7, Staff #5 and Staff #2 to report another youth reported Staff #1 and Youth #1 had been “flirting.” • On 11/28/2024, Staff #8 sent an email to Staff #4 and Staff #6 reporting two youth reported Staff #1 had typed “you’re cute” into his phone and showed it to Youth #1, but did not know the date this occurred. Staff #4 forwarded this email to Staff #2 and Staff #3. • On 11/29/2024, Youth #1 made a report to Staff #9 that Staff #1 had told her that after he had inventoried her underwear/thongs and clothes that he was fantasizing about her in them. Staff #9 discussed the report with his co-worker on shift, Staff #11 and contacted Staff #4. Staff #9 created a written Major Incident Report for this incident on 11/29/2024. Staff #11 sent a follow-up email to Staff #4 on 11/30/2024. Staff #4 signed off on the written MIR on 11/30/2024. • On 12/1/2024, Youth #1’s sister sent an email to Staff #6 of screen shots of Youth #1’s Snapchat messages from Staff #1. Messages included “you are ...

Deficiency cited, complaint inspection

The provider failed to implement YBGR Policy #636 which states, “The Administrator On-Call will ensure that: The alleged staff member(s) do not continue to provide direct care until an investigation is completed.” Staff #1 worked on 11/25/2024, 11/26/2024, 11/27/2024 and 12/01/2024 after the below abuse allegations were made. Staff #1 was not placed on administrative leave until 12/01/2024, part way through his shift. • On 11/25/2024, Staff #10 sent an email to Staff #7, Staff #5 and Staff #2 to report another youth reported Staff #1 and Youth #1 had been “flirting.” • On 11/28/2024, Staff #8 sent an email to Staff #4 and Staff #6 reporting two youth reported Staff #1 had typed “you’re cute” into his phone and showed it to Youth #1, but did not know the date this occurred. Staff #4 forwarded this email to Staff #2 and Staff #3. • On 11/29/2024, Youth #1 made a report to Staff #9 that Staff #1 had told her that after he had inventoried her underwear/thongs and clothes that he was fantasizing about her in them. Staff #9 discussed the report with his co-worker on shift, Staff #11 and contacted Staff #4. Staff #9 created a written Major Incident Report for this incident on 11/29/2024. Staff #11 sent a follow-up email to Staff #4 on 11/30/2024. Staff #4 signed off on the written MIR on 11/30/2024. • On 12/1/2024, Youth #1’s sister sent an email to Staff #6 of screen shots of Youth #1’s Snapchat messages from Staff #1. Messages included “you are fine af”, “Just thinking about you ...

Deficiency cited, complaint inspection

1. The provider failed to meet Title 42 CFR Part 483 Subpart G 364 (a) as referenced in Title 42 CFR Part 441 Subpart D. On 11/17/2024, Staff #1 failed to be physically present in or immediately outside the seclusion room, continually assessing, monitoring, and evaluating the physical and psychological wellbeing of the Youth #1 during a seclusion. This resulted in an injury to Youth #1 requiring medical care. 2. The provider failed to meet Title 42 CFR Part 483 Subpart G 364 (b) as referenced in Title 42 CFR Part 441 Subpart D. Per provider email dated 11/18/2024, the seclusion room used for Youth #1 on 11/17/2024 did not allow staff full view of the resident in all areas of the room. This resulted in an injury to Youth #1 requiring medical care.

Deficiency cited, complaint inspection

The intent of the rule has not been met as evidenced by: The surveyor’s review of incident reports and supervisory reviews.

Deficiency cited, complaint inspection

1. On 08/19/2024, Youth #1 reported to staff that Youth #2 and Youth #3 engaged in sexual activity. On 08/29/2024 the youth admitted to Staff #8 that the incident was true. Staff #8 did not repoprt the incident to CPS until 09/04/2024. 2. On 09/08/2024, Youth #4 reported to Staff #7 that he and Youth #5 engaged in oral sex. Staff #7 did not report the incident to CPS until 09/12/2024. The intent of the rule has not been met as evidenced by: The surveyor’s review of incident reports, high risk assessments, YBGR policies and staff and youth interviews.

Deficiency cited, complaint inspection

1. Staff #1 and #2 did not properly implement policy #520 on 08/19/2024. Staff #1 and #2 did not complete and document bed checks every 15 minutes while the youth were still awake. Youth #1 and #2 state that Staff #1 and #2 were in the office with the door shut, talking, horse playing, on the computer and on their phones during the incident. Youth #1 and #2 also state that during the incident, bed checks were not being done. (Bed check documentation for 8:00 pm and 8:30 pm the night of the incident was not completed until 11:00 pm.) Staff #1 and #2 both state they were in staff office during this time. Staff #2 states that one bed check might have been missed. Staff #2 also states that 5 of the youth were still awake at this time. Youth #1 kept a watch for staff while Youth #2 snuck into Youth #3’s bedroom. Youth #2 and #3 admit to engaging in kissing, digital penetration and oral sex during this time. 2. Staff #3 did not properly implement policy #630 on 09/08/2024. Staff #3 did not provide constant visual observation to Youth #4 while on suicide precautions. At the time of the incident, Youth #4 and Youth #5 were in a fort where Staff #3 could not see them. Staff #3 states that at one point all 3 youth she was supervising were in the fort together where she could not see them. Staff #3 also states that she was pulled away from the fort area by Youth #6 when he asked to get into the kitchen, bathroom and one other place during this time. Youth #4 states that Staff #3 only ...

Deficiency cited, complaint inspection

Intent of the rule is not met as evidenced by: The surveyor’s review of incident reports, grievances, staff statement, and youth and staff interviews.

Deficiency cited, complaint inspection

1. The 11/18/2023 incident report provided to the Licensure Bureau on 11/20/2023 did not include complete details of the incident. Also, an investigation was not conducted, and a written report completed and submitted to the department, including (a)-(e).

Deficiency cited, complaint inspection

1. All youth interviewed at Jessie Grant Lodge on 03/27/2024 and 03/28/2024 reported mice in the unit, including in the heating units and bedrooms. 2. All youth interviewed at Fortin West Lodge on 03/27/2024 reported ants in the unit, including bedrooms and the kitchen. This surveyor toured the kitchen on 03/27/2024 and did observe numerous live ants on the floor. Intent of the rule is not met as evidenced by: The surveyor’s review of incident reports.

Deficiency cited, complaint inspection

The provider failed to follow the below Joint Commission standards: Standard CTS.05.06.35 (15) The facility failed to evaluate and report the injury to Youth #3 on 11/18/2023 to external agencies when Staff #1 reported punching Youth #3 three times and gauging at his eyes. Intent of the rule is not met as evidenced by: The surveyor’s review of master treatment plans.

Deficiency cited, complaint inspection

Youth #1’s MTPR dated 04/01/2024 and Youth #2’s MTPR dated 03/18/2024 do not include the below as required by 42 CFR 456.180: (1) Diagnoses, symptoms, complaints, and complications indicating the need for admission; (2) A description of the functional level of the individual; *** (4) Any orders for— (i) Medications; (ii) Treatments; (iii) Restorative and rehabilitative services; (iv) Activities; and (v) Therapies;

Deficiency cited, complaint inspection

The surveyors review of incident reports dated 7/15/21, 7/26/21 (incident time 1740), 7/26/21(incident time 1710), 11/16/21, 12/21/21, 12/27/21, 12/29/21 supervisory reviews dated 07/15/21, 07/26/21, 7/26/21, 12/27/21, Serious incident and investigation report for serious incident dated 12/29/21, resident #1's major incident reports dated 12/2/21 12/29/21, nursing notes, suicide precautions 12/21/2021 12/23/2021 and 12/26/21- current, close watch orders 12/23/21 - 12/26/21, resident #2's major incident reports and precautions 12/1/2021 - 12/27/21, the providers policy manual, 20 interviews with staff and residents, and an on-site inspection on 1/10/2022-1/11/2022.

Deficiency cited, complaint inspection

(1) The facility has failed to provide a safe environment for residents by not providing adequate supervision of residents and by not securing sharps, contraband, and other household items residents were using to inflict serious harm on themselves as outlined below:

Deficiency cited, renewal inspection

The surveyors review of resident records, personnel records and facility records on 08/19/2021, 08/23/2021, 08/31/2021 and 09/01/2021.

Deficiency cited, complaint inspection

The surveyors review of incident reports dated 05/17/21, 06/09/21, 06/10/21, 06/15/21 and 6/18/21, supervisory reviews dated 05/18/21,06/21/21, 06/22/2021, and 06/23/21, and the providers policy manual on 06/22/21.

Deficiency cited, complaint inspection

The surveyors review of incident reports and interviews on 10/13/2020 - 10/30/2020.

Deficiency cited, complaint inspection

(1) The facility failed to follow the reporting guidelines of MCA 53-21-107(3).

Deficiency cited, complaint inspection

(1) The facility failed to follow the reporting guidelines of MCA 53-21-107(3). - On 09/09/20 resident #1 reported to facility staff that her shop teacher at school had asked her if she has ever has sex, asked her if she would have sex with him, kissed her, and showed her a video; on his cell phone, of himself playing with his penis. The facility conducted a full investigation in regards to the incident on 09/09/20, interviewed staff and residents. The facility closed the investigation stating it was a "he said", "She said" allegations and did not report the allegations to the proper authorities. - The facility did not report the allegation by the end of the next business day, in writing to the Board of Visitors pursuant to MCA 53-21-107(3)(b). - The facility did not report the allegation of abuse that constitute a criminal act did not report the allegation to the appropriate law enforcement authority pursuant to MCA 5321-107(3)(c).

Deficiency cited, complaint inspection

(1) The facility failed to follow Policies 636 and 639, which requires all incidents involving a report of abuse and/or neglect involving a client in treatment to be reported in compliance with MCA 53-21-107 and MCA 41-3-102 and within one (1) business days to the Licensure Bureau regarding the incident that occurred on 09/09/2020. Plan of Correction: Review of the existing policies determined there were no changes required. Additionally, a staff guidance resource was created for reporting that includes the changes to the Admin On Call mentioned in the previous section. To protect the integrity of the investigation of abuse or neglect allegations the Admin On Call process will be used and the administrator who responds will inform the ELC group on the details and process. This helps ensure that the entire team is aware of the information and can respond quickly and will also hold each other accountable to the policies. Policy 639 and 636 were reviewed with the ELC team. COMPLETION DATE: 11/16/2020

Deficiency cited, renewal inspection

The surveyors record review on September 08, 2020 September 17, 2020.

Deficiency cited, renewal inspection

(1) 42 CFR 441.154: - Residents #1, #4, #6, #7, and #8’s initial treatment plans were not developed and implemented within 14 days of admission into the facility.

Deficiency cited, complaint inspection

The surveyor’s review of individual plans of care, admission evaluations, orders, medication check notes, physician invoices and team staffing notes on July 20 through July 30, 2018.

Deficiency cited, complaint inspection

42 CFR 441.151 (b) and 42 CFR 483.374 (2) There is no documentation that parental notification occurred within 24 hours regarding the self-harm/suicide attempt incident that occurred on 7/16/18 for Resident #3.

Deficiency cited, complaint inspection

42 CFR 441.156 (a and c) The individual plans of care for Resident #1, Resident #2 and Resident #3 are not developed by an interdisciplinary team of physicians. The team does not include a physician licensed to practice medicine or a Board-eligible or Board-certified psychiatrist. The individual plans of care are being developed, updated and overseen by a Physician Assistant.

Deficiency cited, complaint inspection

1. The facility did not document 7 (a-e) above in writing for allegations of abuse or neglect regarding: Resident #1 incident on 7/15/2018. Resident #2 incidents on 7/20/2018 and 7/23/2018. Resident #3 incidents on 6/9/2018, 6/17/2018, 7/15/2018 and 7/16/2018.

Deficiency cited, complaint inspection

The facility did not provide a copy of the written report as described in MCA 53-21-107(7)(a) through (7)(e) within 5 working days of the completion of the investigation to the departments Licensure Bureau regarding Resident #3’s selfharm/suicide attempt on 7/15/2018.

Deficiency cited, complaint inspection

CTS.01.03.01 (2) The preliminary plan for care, treatment, or services focuses on the individual’s safety. The preliminary plan for care included in the admission evaluation for Resident #1 identifies an extreme history of selfharm. The plan of care did not identify interventions to address Resident #1’s safety.

Deficiency cited, complaint inspection

EC.02.01.01 (3) The organization takes action to minimize identified safety and security risks associated with the physical environment. Resident #3 had incidences of self-harm/suicide attempt by cutting using metal outlet covers on 6/9/2018, 6/17/2018, 7/15/2018 and 7/16/2018. The organization did not take action to minimize identified safety risks regarding the outlet covers in Resident #3’s bedroom. Adequate action was not taken until 7/23/2018 upon request from the Licensure Bureau.

Deficiency cited, complaint inspection

RC.02.03.07 (4) Verbal orders are authenticated within the time frame specified by law and regulation. The medical record for Resident #3 had over 12 telephone/verbal orders dated between 6/9/2018 and 7/20/2018 that had not been authenticated (signed) by the physician giving the order.

Deficiency cited, complaint inspection

1. The 4/27/2018 individual plan of care for Resident #1 does not include a comprehensive discharge plan. 2. The 6/26/2018 individual plan of care for Resident #2 does not include a comprehensive discharge plan.

Deficiency cited, complaint inspection

As evidenced by this surveyors Policy and Procedures review and Report of Search review on 3/22/17

Deficiency cited, complaint inspection

1. Report of Search from 11/17/16 and 12/5/16 on Youth #1 did not have a signature authorized by a Director or Therapist as per required policy. .