facility_name: Madrona Recovery

summary: License Renewals - 4 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care
Licensee: Madrona Recovery Date of site visit: 2-10-21
Executive Director: Charley Downing Licensing Coordinator: Todd Cooley
Board Chairperson: Michael Knapp
Other Regulatory or Accrediting Agencies: OHA, ODHS Treatment Services
Program Compliance: The program was found to be compliant or will be compliant with OAR 413-215-0001 to 413-215-0131, Licensing Umbrella
Rules, and OAR 413-215-0501 to 413-215-0586, Licensing Residential Care Agencies Rules. Personnel records were reviewed and compliance
with required background checks was documented for employees in all programs.
Program Description(s): Madrona Recovery’s residential program focus on community, accountability, and relationships. The residential program
has an inter-disciplinary clinically grounded team, who work closely with Qualified Mental Health Associates and Certified Recovery Mentors who
provide a therapeutic milieu where youth are challenged to develop skills to prevent relapse and provided education to best equip them to support
their own mental health and recovery needs.
Program type and services: Residential and BRS
Capacity (gender and ages): 26 – ages 13-17
Funding sources: Kaiser, MHN, BCBS, 1st Choice, PacSource, Optum, Providence, Good Sam, Healthnet
Contracts and sources for referrals: Emergency Departments, community providers, website, alumni
Average length of stay: Residential – 21 days; BRS – 45 days
Average daily population served: 13
Number of children served annually: 155
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 08/13/2020)
Use of seclusion or restraint: No seclusion. Use therapeutic holds by staff trained in CPI
Interviews, Observations: During the review the Founder/CEO John Thornton, Exec. Dir. Charley Downing and COO/CFO Micah Brathwaite were
on hand for entrance interviews, exit interviews and available for any questions throughout the day. Three residents were also interviewed during
this review.
The residents had been in the program 1-2 weeks and one of them had been a resident prior for approximately a month. There were some
common themes among the residents during the interviews. All stated they felt safe in the program and did not have any concerns around safety.
They felt most staff really cared and all had staff they were comfortable talking with if they had any concerns. All felt the food was good and
portions were plentiful with snacks available if they got hungry between meals.
There were mixed opinions on recreation. While all felt there was plenty of free time, some stated outside activities were limited due to basketballs
being flat and not having access to the goats unless you were in crisis. There did not seem to be clear messaging around interacting with the
program’s goats as some residents felt you could interact with them whenever, but this particular resident chose not to, and others felt only those
residents in crisis had the opportunity to feed or pet the goats. It was suggested items like sidewalk chalk might make outdoor rec more enjoyable
for some who don’t like to participate in things like basketball. Weather was also a factor and the residents said they choose not to go outside just
because it is really cold.
Another common theme was overall chaos and lack of structure. The residents stated with the current milieu there are a lot of loud and strong
personalities who enjoying engaging in drama for the sake of drama. This occurs during the day as well as at night sometimes making it difficult to
sleep or find a quiet space. Residents felt staff did not do a good job of calming things down a lot of times when it would get loud which made it feel
chaotic. This gave some residents the impression as well that some of their peers were “rewarded” for acting up because there were really no
consequences for their actions. They got this impression because staff had to dedicate much of their time to those residents who were acting out
and that would take time away from those participating and sometimes cause them to miss out on things they were supposed to do because staff
were not available. As far as structure, there is a set schedule but one of the residents interviewed said the schedule was rarely kept to due to
peers acting out and not being able to transition. This resident gave the impression they came from a very structured household as they thought in
addition to a more rigid schedule the residents should also have a lot more chores and responsibilities during their stay.
All interviewed residents agreed the groups (therapy) were really good. They felt the topics were on point and they were learning something in
every group. The groups were all found to be helpful towards reaching their goals. They did state they could get sidetracked by peers being
obnoxious and talking a lot but were still able to focus and take away something positive.
John and Charley also provided the tour of the facility which was found to be clean and in good repair. The bedrooms appeared well kept and the
common areas and bathrooms were all very clean. Lunch was being prepared in the kitchen at the time of the tour and there were no concerns
over food prep or storage that were immediately apparent. The outdoor recreation area is now about twice the size it originally was as Madrona
Recovery has recently acquired the adjacent building for their outpatient program and have been able to fence the area in between. This is a
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marked improvement in the outdoor recreation area providing more space for basketball, additions of some raised garden beds and a new space for
the programs two goats.
One observation of note during the tour, and discussed at the exit interview with management, was an observed interaction with a group of three
residents and one staff. While moving through the hallway there were three female residents with high energy in close proximity to a male staff.
The three residents seemed to be feeding off each other’s energy and the staff appeared to not be setting boundaries and possibly a bit flustered at
the situation. Another staff was observed down the hall just watching the interaction and not making an attempt to intervene or calm the situation.
Our group moved on past the commotion in the hall, but the scene made an impact on licensing and other regulators. It was brought to
managements attention that staff might benefit from some additional training and support around boundaries. This observation was in line with what
was heard during the resident interviews about high energy and “chaos”. For context it is also understood the behavior, energy level and tone of a
milieu is always in flux as residents come and go, and the group in care at the time of the review was particularly challenging.
Program Strengths, as identified by the program: Resilience. We are in our 3rd year. Staff retention has improved more recently. Groups. The
quality of the content is high, client engagement has increased, according to our surveys, clients find our groups/group leaders relavent and
valuable to their treatment experiences. Therapeutic alliance is strong. By design, we have low caseloads, highly qualified professionals and a
(relatively) small population of clients. These are ingredients that produce positive outcomes.
Program Challenges, as identified by the program: The population of clients we serve is very challenging. Generally speaking, we are up for
this challenge; we sign up for it. However, turnover is high when staff express they do not feel safe. We have had several assaults on the unit that
have resulted in valuable staff leaving. This puts additional stress on staff who remain. Assaultive clients who remain in our program due to limits
of available community options has been cited as a main reason for staff expressing this safety concern.
Covid-19. We've had two cases. This makes staff, parents, everyone anxious. We've lost good staff and have had to press pause on admissions,
which puts a stress on the agency’s finances.
Attempting a much-needed outpatient program has proven challenging to begin and grow during this time.
Medical Leadership was highly problematic. That concern has been resolved.
Changes that have occurred in the last 2 years, as described by the program: Contracting with DHS to provide BRS services to a larger
number of teenagers in the CW system. Medical Director changed within the last two years. We are well served by Dr. Joel Suckow since this
change occurred.
We received our Intensive Outpatient Services and Support (IOSS) license and began serving families in an outpatient capacity in December of
2020.
Lawsuits: No lawsuits to date
Grievances and complaints filed in the last two years: No significant grievances. Documentation provided and on file.
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Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report Madrona Recovery must submit a letter of verification indicating the agency is in compliance with the specific
rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency must submit any
and all specific documentation requested in the body of this report. The letter of verification and any additional requested documents can be emailed
directly to Todd Cooley, todd.cooley@dhsoha.state.or.us , or sent by regular mail to the following address:
Department of Human Services, Children’s Care Licensing Program
Attn: Todd Cooley
201 High St SE, Suite 500
Salem, OR 97301
Exceptions: Exception on file for no window egress in bedrooms. Exception on file for the annual financial review or audit.
Changes in License: None
Summary of Review
Program and Services Corrective Action
Yes No N/A Corrective Actions
413-215-0011(2) Completed
Program and services are in scope of license
X
Governance of the Agency Corrective Action
Yes No N/A Corrective Actions
413-215-0021 Completed
(1)(a) Minimum of 5 board members X
(2)(f) Formally evaluate the exec. Director’s
X
performance annually
(2)(g) Approves annual budget X
(2)(h) Obtain and review an annual  Exception on file for audit
independent financial review or audit of X
financial records.
(2)(k) Written quality improvement program X
(2)(l) Meeting minutes X
Executive Director or Program Director Corrective Action
Yes No N/A Corrective Actions
413-215-0021 Completed
(3)(a) knowledge of requirements for
providing care and treatment appropriate to X
programs
(3)(g) Approval from BCU X
Discipline, Behavior Management, and Corrective Action
Yes No N/A Comments
Suicide Prevention 413-215-0076 Completed
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(3) Agency uses appropriate and positive
methods of behavior management and
X
nationally recognized non-violent crisis
intervention
(3)(b)(C) Agency does not use chemical and
mechanical restraint (excluding medically X
necessary devices/prescriptions)
(3)(c) Agency uses appropriate time-out
rooms (adequate space, heat, light and
ventilation and is not capable of locking) and X
documents use in child’s record when
applicable
(3)(e) Agency uses seclusion
X
appropriately/consistent with policy
(4) Agency has adequate plan in place to
X
respond to suicidal behavior/warning signs
Physical Plant Corrective Action
Yes No N/A Corrective Actions
Completed
413-215-0046(3)(a) Foster Rights Posted (if
X
children in DHS custody)
413-215-0051(1) Sufficient safe space,
X
equipment, and office equipment
413-215-0091(12) License is posted in
X
common area at each facility
413-215-0001(5)(d), 0516(4(a)(I) & 0521(1)
X
Adequate furnishings and personal items
413-215-0511(2)(a) &(c) Buildings are
X
smoke free, clean and in good repair
413-215-0511(2)(d) Rooms are free of
X
harmful drafts, odors, and excessive noise
413-215-0511(2)(e) Rooms are adequate in
X
size and arrangement
413-215-0511(2)(f) System provides a
continuous supply of hot and cold water to X
taps located throughout the facility
413-215-0511(2)(h) Building is well
ventilated and room temperature is within a X
normal comfort range
413-215-0516(1) All parts of the facility
X
ensure the safety of children
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions
Bedrooms 413-215-0516(3) Completed
(a) Adequate furnishings and personal items X
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(b) Separate from rooms used for dining,
X
living, laundry, kitchen, and storage
(c) Outside room with window allowing
X
egress from building
(d) Ceiling at least 90 inches X
(e) Minimum 60 SF per bed X  Exception on file for window egress.
(f) No more than 25 if dorm style X
(g) Permanently wired fixtures X
(h) Window covering X
(i) Beds are 3 feet apart and maintained to
X
ensure safety
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions
Bathrooms 413-215-0516(4) Completed
(a)(A)&(B) 1:8 ratio for toilets and sinks X
(a)(D) Hot and cold running water, soap, and
X
approved hand drying options
(a)(E) 1:10 ratio for shower or bathtub X
(a)(E) Individual privacy X
(a)(F) Window covering X
(a)(G) Permanently wired fixtures X
(a)(H) Adequate ventilation X
(b)&(c) Wooden racks on floors are
prohibited and impervious shower mats are X
disinfected & dried daily
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions
Kitchen 413-215-0516(6) Completed
(a) Used exclusively for storage, food
preparation, dish washing and activities X
related to eating
(b) Walls, floors are easily cleanable X
(c) Equipment and utensils are easily
X
cleanable, durable, nontoxic, and kept clean
(e) Equipment is easy to clean beneath,
X
between and behind
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions
413-215-0516 Completed
(2) There is a separate living room or lounge
X
area – 15 SF minimum per child
(5) There is a separate dining room with
capacity for ½ of children in care and 15 SF X
per child in care
(7) Laundry is separate from living areas,
X
kitchen and dining
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(8) Separate storage areas are provided for
food, kitchen supplies, utensils, clean linens,
soiled linens and clothing, cleaning supplies X
and equip, poisons, chemicals, outdoor
recreational and maintenance equipment
(9) Outdoor activity area is protected from
vehicles and other hazards and of a size and
X
availability appropriate to the age and needs
of children in care
(11) & 413-215-0076(3)(c)(C)Time out rooms
have adequate space, heat, light and X
ventilation and is not capable of locking
Furnishings and Personal Items Corrective Action
Yes No N/A Corrective Actions
413-215-0521 Completed
(1) There is a bed with frame, clean mattress
and pillow and personal storage (dresser, X
closet)
(2) Linens are in good repair. There is a
waterproof mattress cover or mattress.
X
Linens are appropriate and towels and
washcloths are provided
(3) Bedding is changed weekly or when
X
soiled
(4)&(5) Personal hygiene supplies and
X
appropriate clothing are provided
Food Services Corrective Action
Yes No N/A Corrective Actions
413-215-0536(1)&(2) Completed
(1)(a) Meals are arranged daily, consistent
with normal mealtimes that occur during the X
hours of operation
(1)(b) Menus are prepared in advance in
accordance with USDA guidelines, provide a
X
variety of foods and are adjusted for
seasonal changes.
(1)(b) Menus are kept for at least 6 months X
(1)(c) Drinking water is freely available X
(2)(a) Food is stored, prepared & served in a
X
sanitary manner
(2)(c) & (d) Food products are obtained from
commercial suppliers (exception of fruits &
vegetables), unpasteurized juice is X
prohibited, and only Grade A pasteurized
and fortified milk in appropriate container.
Safety Corrective Action
Yes No N/A Corrective Actions
413-215-0541 Completed
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(2)(a) Written emergency plan X
(2)(b) Telephone numbers for local police
X
and fire are posted near all telephones
(2)(c) Operative flashlights sufficient in
X
number are readily available to staff
(3)(a) Evacuation drill occurs monthly under
varying conditions, is retained 2 yrs and
contains;
(A) identify of person conducting drill
(B) date & time
(C) notification method X
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
Safety – Transportation Corrective Action
Yes No N/A Corrective Actions
413-215-0541 Completed
(5)(b) Vehicle has insurance policy, is smoke
free, safe operating condition, and has first X
aid kit and fire extinguisher 2-A:10-BC
Medication Corrective Action
Yes No N/A Corrective Actions
413-215-0551 Completed
(3)&(7)(e) Medications have a prescription
and are stored in the original container with X
prescription label
(4)&(5) Herbal supplements and remedies,
medical treatments, special diets, physical
therapy, physical aides or limitations have a X
written order signed by a physician or
qualified medical professional.
(7)(c) Medications are inaccessible to
X
children
(8) Medications are disposed in accordance
X
with state and federal law
(9) Written record of the disposal of
medications is maintained and includes:
(a) description and amount
(b) name X
(c) reason
(d) method
(e) staff & witness signature
(10) Written record of the administration of
medication includes: X
(a) name
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(b) description
(c) dates and times
(d) missed doses
(e) medication disposed
(f) method of administration
(g) ID of person administering
(h) possible adverse reactions
(i) medication taken outside facility
Extracurricular, Enrichment, Cultural &
Corrective Action
Social Activities Yes No N/A Corrective Actions
Completed
413-215-0554
(2) Children have ongoing opportunities to
participate in at least one age-appropriate or X
developmentally appropriate activity
Minimum Staffing Requirements Corrective Action
Yes No N/A Corrective Actions
413-215-0561 Completed
(1)&(2) Supervision is adequate for the type
of program, location, age and type of
children, ability of supervisor to respond,
electronic back-up systems.
Minimum ratios are maintained:
Under 30 months of age: 1:4 X
30 months to ˃ 6 yrs or non-ambulatory: 1:6
Ages 6 and older: 1:7
Overnight (staff awake)
1:10
(4)(a) When one staff on duty, there is
additional staff immediately available with X
max response time of 30 minutes
(5) There is at least one on-site employee
authorized to apply the reasonable and X
prudent parent standard
Separation of Residents Corrective Action
Yes No N/A Corrective Actions
413-215-0566 Completed
(1) Children are in separate bedrooms than
adults, unless parent and child, or there is
X
written approval from guardian/parent and
licensing coordinator
(2) There is adequate supervision of children
if both males and females are served by the X
program
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Supplemental Information Provided by Corrective Action
Yes No N/A Comments
CCA Completed
Documents as indicated on the form titled
X
“Renewal Licensing Required Documents”
Documents as indicated on form titled
“Required Financial Documents and X
Information”
All required policies and procedures as
X See Comments
identified in the “Umbrella Rules”
All required policies and procedures as
X
identified in “Agency Type Specific Rules”
Comments:
Madrona Recovery provided all required policies and procedures. During the interview process it was discovered their practice was not in alignment with their
policy on rights of children and families. Residents disclosed having a 72-hour restriction on phone calls/contact with their guardians upon being admitted to the
program. Management confirmed this practice and stated both residents and guardians were made aware prior to entry into the program. Licensing informed
Madrona Recovery this practice is in violation of rule and their own policy and requested the practice be stopped immediately. Licensing is working with
Madrona Recovery to ensure practices match policy.
OAR 413-215-0081- Application for License, Renewal, or to Add a Program: (B) Written policies regarding the rights of children and families the child caring
agency would serve upon being licensed that meets the requirements of OAR 413-215-0046.
413-215-0046
Licensing Umbrella Rules: Children and Families Rights Policy and Grievance Procedures
(1) Rights of children in care and families served by the child-caring agency. A child-caring agency must guarantee the rights of children in care and the families
the child-caring agency serves. A child-caring agency must enact and adhere to a policy ensuring those rights. A written copy must be distributed to all children
in care and families served by the child-caring agency, and afford the following rights:
(a) Except as provided in paragraph (B) of this subsection, the child in care's right to uncensored communication with legal guardians, caseworkers, legal
representatives, and other persons approved for communication by the legal guardian or as provided in a court order.
(A) This right cannot be waived, including voluntarily. Restriction on communication between a child in care and his or her legal guardian may not be a condition
of participation in the program.
(B) A child-caring agency may place reasonable limits on communication, but only as provided in the child-caring agency's policy. Reasonable limits include, but
are not limited to, having set time periods during the day for visitation and phone calls and imposing moderate limits on the duration of calls or visits. However, a
limitation is not considered reasonable if it prevents the ability to meaningfully communicate, such as not allowing contact with a child in care's attorney during
regular business hours.
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Personnel Files Corrective Action
Yes No N/A Corrective Actions
413-215-0061 Completed
Staff Name/Position X
(3)(g) Date of Hire X
(3)(a) record of education, training and
X
previous employment
(1)(b) & (3)(b) reference checks completed
X
and documented
(1)(a) & (3)(c) Background check completed  One of the files reviewed included staff who had
X
and documented received a promotion and a new background check
had not been conducted per rule.
(3)(d) Annual performance evaluations X
(3)(f) Record of personnel actions X
(3)(g) Termination date, reason for
X
termination
(3)(h) Current job description (1)(c)
Employee meets minimum qualifications X
stated in current job description
New Employee Orientation – Umbrella
Corrective Action
Requirements (30 days) Yes No N/A Corrective Actions
Completed
413-215-0061(4)
(a) Agency policies and procedures X
(b) Ethical and professional guidelines X
(c) Organizational lines of authority X
(d) Attributes of population served X
(e) & (5)(a) to (c) Mandatory reporting that
includes:
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter 106,
X
section 36
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
(f) Privacy laws X
(g) Emergency procedures X
New Employee Orientation – Residential
Corrective Action
(30 days) Yes No N/A Corrective Actions
Completed
413-215-0556
(1)(a) Discipline and behavior management
X
including de-escalation, crisis prevention,
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positive behavior management, and
disciplinary techniques that are non-punitive
in nature
(1)(b) Restraint and seclusion (if applicable) X
Ongoing Training Corrective Action
Yes No N/A Corrective Actions
Completed
413-215-0536(2)(b) Employees who handle
food served to children have a valid food X
handler’s card
413-215-0541(5)(a) Employees transporting
children have: current driver’s license,
insurance, trained in emergency procedures X
and behavior management, and training for
15+ passenger vans if applicable)
413-215-0556(2)(a) Environmental
X
emergencies
413-215-0556(2)(b) Universal Precautions X
413-215-0556(2)(c) Discipline and Behavior
X
Management
413-215-0556(3) Staff providing direct care
must maintain current CPR/First Aid X
certification
413-215-0556(4) Designated staff authorized
to apply reasonable and prudent parent
X
standard are trained in application of the
standard
413-215-0061(5) Mandatory reporting
(annually) that includes:
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter 106,
X
section 36
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
Contractors (if applicable) Corrective Action
Yes No N/A Corrective Actions
413-215-0061(6) Completed
(a) Agency ensures the contractor meets the
requirements of this rule and Chapter 413 X
division 215
(b)(B) Contract includes the following:
X
(i) Services provided
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(ii) Contractor fees
(iii) Disclosure of information from contractor
to agency
(iv) Lines of authority
(v) Adherence to rules, including background
check
(vi) Any liability of the agency for acts of the
contractor, rights of indemnity and limitations
on liability
Comments:
Children’s Records Corrective Action
Yes No N/A Corrective Actions
Completed
Health Services
413-215-0546
(2) Medical history obtained within 30 days
(significant findings, current immunizations,
history of surgical procedures-health issues- X
injuries, allergies, dental, vision, hearing,
behavioral health, and physician orders)  There was no documentation of age appropriate
(2)(e) Documentation of age appropriate instruction. Madrona Recovery plans to add this to
instruction – pregnancy prevention, nutrition, the nursing assessment at intake so any concerns
prevention of HIV & AIDS, and prevention X around diet, pregnancy prevention, STDs, etc. can
and treatment of sexually transmitted be discussed with the nursing staff.
disease
(4)(a) to (f) Medical exams (3 in first year of
life, 2,4,6,9,14) X
Consents Corrective Action
Yes No N/A Corrective Actions
413-215-0576(1) Completed
(a) Provide routine and emergency medical
X
care
(b) Use the discipline and behavior
X
management system
(c) Use restraint or seclusion (if applicable).
Must specify the reasons for the intervention X
and how staff are trained and supervised
(d) Restrict contact with persons outside of
X
the agency
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(e) Allow access as defined in 413-215-0091
X
& 0101
(f) Impose a dress code X
(g) Apply the reasonable and prudent parent
X
standard
Disclosures
Corrective Action
413-215-0576(2) Parent/guardian has Yes No N/A Corrective Actions
Completed
acknowledged in writing:
(a) Information regarding personal or room
searches and protocols for confiscation of X
contraband
(b) Statement of Rights of Children and
X
Parents/Guardians
(c) Any policies and procedures upon
X
request
Authorizations Corrective Action
Yes No N/A Corrective Actions
413-215-0576(3) Completed
(a) Disclose or exchange information with
X
others
(b) Child specific visitors X
(c) Visitation resources are pre-approved X
(d) Activity specific authorizations are pre-
approved to allow children to participate in
potentially hazardous activities, including but X
not limited to using motorized yard
equipment, swimming, and horseback riding.
Information about Children in Care
Corrective Action
413-215-0581(1) Summary sheet contains Yes No N/A Corrective Actions
Completed
the following:
(a)The name, gender, date of birth, religious
X
preference, and previous address
(b) Name and location of previous and
X
current school
(c) Date of admission X
(d) Legal custody X
(e) The name, address, and telephone
number of:
(A) The child in care's parents.
(B) The child in care's legal guardian, if X
different than the parents, and a copy of
the document that provides for his or her
authority over the child in care.
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(C) Other persons significant to child
(D) Other professionals to be involved in
service planning (if applicable)
Service Planning Corrective Action
Yes No N/A Corrective Actions
413-215-0581(2) Completed
(b) Intake document is completed the date
child accepted into care (emergency X
placement 48 hours)
(d) Assessment is completed within 30 days
and contains relevant historical info., current
behavioral observations, identified need for X
services, and how agency will provide
services
(e) (A)&(B) Service plan within 60 days
(parent, guardian and child actively
involved). Describes how child’s issues will X
be addressed, anticipated outcomes and
reviewed by child and guardian/parent.
(e)(C)&(D) Service plan is reviewed quarterly
and revised when information indicates other X
services should be provided
Case Management Corrective Action
Yes No N/A Corrective Actions
413-215-0581(3) Completed
(a) Services are documented, progress
X
toward achieving goals is tracked
(b)-(d) discharge planning and instructions X
(f) Incident Reports X
Financial Records Corrective Action
Yes No N/A Corrective Actions
413-215-0581(4) Completed
Records contain date, amount, source,
X
purpose, signatures
Personal Possessions Records Corrective Action
Yes No N/A Corrective Actions
413-215-0581(5) Completed
Individual written inventory of all personal
possessions is maintained and updated as X
needed
Records and Documentation Corrective Action
Yes No N/A Corrective Actions
413-215-0071 Completed
(1) Stored safely X
(2) Permanent, legible, dated, and signed X
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(3)&(4) Uniform in organization, readily
identifiable and accessible, current, and
X
complete, containing all required info. No
eraser tape or white out.
(7) Permanent registry for each child
includes:
Name
Gender
X
Birth date
Names, addresses of parents or guardians
Dates of admission
Placement upon discharge
Comments:
Consents were originally vague around use of the discipline and behavior management and essentially only stated they would use the discipline and behavior
management system. Program Director Downing expanded this section to identify the system being used, the Crisis Prevention Institute (CPI) system, which
will enable clients and guardians to find additional information if they choose.
Residents at Madrona Recovery do not participate in off-site recreational activities, and the activities on site are not high-risk, so a disclosure and consent for
these types of activities isn’t required and isn’t part of the intake process.
Due to the nature of the program and length of average stays, none of the files reviewed belonged to residents who had been in the program long enough to
require a 60-day service plan or quarterly review of the service plan.
3-1-2021
Licensing Coordinator’s Signature: ________________________ Date: ___________________
02-26-2021
Manager Review: ______________________________________ Date: __________________
16

agency_name: Madrona Recovery (MR)

licensee: Madrona Recovery

executive_director: Charley Downing

board_chairperson: Michael Knapp

other_regulatory_agencies: OHA, ODHS Treatment Services

program_description:
Madrona Recovery's residential program focus on community, accountability, and relationships. The residential program
has an inter-disciplinary clinically grounded team, who work closely with Qualified Mental Health Associates and Certified Recovery Mentors who
provide a therapeutic milieu where youth are challenged to develop skills to prevent relapse and provided education to best equip them to support
their own mental health and recovery needs.

program_services:
Residential and BRS
Capacity (gender and ages): 26 - ages 13-17

average_length_of_stay: Residential - 21 days; BRS - 45 days

interviews_observations:
During the review the Founder/CEO John Thornton, Exec. Dir. Charley Downing and COO/CFO Micah Brathwaite were
on hand for entrance interviews, exit interviews and available for any questions throughout the day. Three residents were also interviewed during
this review.
The residents had been in the program 1-2 weeks and one of them had been a resident prior for approximately a month. There were some
common themes among the residents during the interviews. All stated they felt safe in the program and did not have any concerns around safety.
They felt most staff really cared and all had staff they were comfortable talking with if they had any concerns. All felt the food was good and
portions were plentiful with snacks available if they got hungry between meals.
There were mixed opinions on recreation. While all felt there was plenty of free time, some stated outside activities were limited due to basketballs
being flat and not having access to the goats unless you were in crisis. There did not seem to be clear messaging around interacting with the
program's goats as some residents felt you could interact with them whenever, but this particular resident chose not to, and others felt only those
residents in crisis had the opportunity to feed or pet the goats. It was suggested items like sidewalk chalk might make outdoor rec more enjoyable
for some who don't like to participate in things like basketball. Weather was also a factor and the residents said they choose not to go outside just
because it is really cold.
Another common theme was overall chaos and lack of structure. The residents stated with the current milieu there are a lot of loud and strong
personalities who enjoying engaging in drama for the sake of drama. This occurs during the day as well as at night sometimes making it difficult to
sleep or find a quiet space. Residents felt staff did not do a good job of calming things down a lot of times when it would get loud which made it feel
chaotic. This gave some residents the impression as well that some of their peers were "rewarded" for acting up because there were really no
consequences for their actions. They got this impression because staff had to dedicate much of their time to those residents who were acting out
and that would take time away from those participating and sometimes cause them to miss out on things they were supposed to do because staff
were not available. As far as structure, there is a set schedule but one of the residents interviewed said the schedule was rarely kept to due to
peers acting out and not being able to transition. This resident gave the impression they came from a very structured household as they thought in
addition to a more rigid schedule the residents should also have a lot more chores and responsibilities during their stay.
All interviewed residents agreed the groups (therapy) were really good. They felt the topics were on point and they were learning something in
every group. The groups were all found to be helpful towards reaching their goals. They did state they could get sidetracked by peers being
obnoxious and talking a lot but were still able to focus and take away something positive.
John and Charley also provided the tour of the facility which was found to be clean and in good repair. The bedrooms appeared well kept and the
common areas and bathrooms were all very clean. Lunch was being prepared in the kitchen at the time of the tour and there were no concerns
over food prep or storage that were immediately apparent. The outdoor recreation area is now about twice the size it originally was as Madrona
Recovery has recently acquired the adjacent building for their outpatient program and have been able to fence the area in between. This is a
2
marked improvement in the outdoor recreation area providing more space for basketball, additions of some raised garden beds and a new space for
the programs two goats.
One observation of note during the tour, and discussed at the exit interview with management, was an observed interaction with a group of three
residents and one staff. While moving through the hallway there were three female residents with high energy in close proximity to a male staff.
The three residents seemed to be feeding off each other's energy and the staff appeared to not be setting boundaries and possibly a bit flustered at
the situation. Another staff was observed down the hall just watching the interaction and not making an attempt to intervene or calm the situation.
Our group moved on past the commotion in the hall, but the scene made an impact on licensing and other regulators. It was brought to
managements attention that staff might benefit from some additional training and support around boundaries. This observation was in line with what
was heard during the resident interviews about high energy and "chaos". For context it is also understood the behavior, energy level and tone of a
milieu is always in flux as residents come and go, and the group in care at the time of the review was particularly challenging.

lawsuits: No

excerpt:
(2)(h) Obtain and review an annual
independent financial review or audit of
financial records.

excerpt:
(c) Outside room with window allowing
egress from building

excerpt: See Comments

excerpt:
(1)(a) & (3)(c) Background check completed
and documented  There was no documentation of age appropriate
instruction. Madrona Recovery plans to add this to
the nursing assessment at intake so any concerns
around diet, pregnancy prevention, STDs, etc. can
be discussed with the nursing staff.


state: OR

summary: Unannounced - 2 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Madrona Recovery
Executive Director: Charley Downing
Program Director(s): Michael Knapp
Date of Unannounced: 06/07/2021
Licensing Coordinator: Aubrey Kelly
Other Regulatory or Accrediting Agencies: OHA, ODHS Treatment Services
Purpose: Per OAR 413-215-0101 (1) (b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings: Repeat Comments
License Renewal Site Visit 02-10-2021 Findings
Further Action
Needed
413-215-0061(1)(a) & (3)(c) Background Yes☐ No Two background checks of recently promoted staff were reviewed and it was confirmed
check completed and documented: “One of new background checks were completed as required.
the files reviewed included staff who had
received a promotion and a new background
check had not been conducted per rule.”
413-215-0546(2)(e) Documentation of age Yes☐ No The nursing assessment that is completed when a client is admitted to the program was
appropriate instruction – pregnancy reviewed and the assessment contains the required information.
prevention, nutrition, prevention of HIV &
AIDS, and prevention and treatment of
sexually transmitted disease: “There was no
documentation of age appropriate instruction.
Madrona Recovery plans to add this to the
nursing assessment at intake so any concerns
around diet, pregnancy prevention, STDs, etc.
can be discussed with the nursing staff.”
1
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
New Findings from Site Visit Comments
None
Interview Summary
Client #1: They have been at the program since May 21st. They were previously at another program and likes it
here better because this program teaches more coping skills. They feel safe here and have not had a time when
they felt unsafe. They get along with the other clients and staff. The food is good, they like the hamburger helper
and crepes. They see their therapist one time a week. They have calls with family two times a day and has virtual
visits with family on Saturdays and Sundays. They like the showers here and the beds are comfortable. They are
hoping to be discharged in 11 days.
Client #2: They have been at the program for one week. They previously had been at two different hospitals.
They like it here, it’s much better than the hospital. Staff members here are in touch and knows how to deal with
mental health issues. After discharge, the plan is to go home. They feel safe here and have not had a time when
they felt unsafe. No one has placed their hands on them since admission. They get along well with staff, they like
the staff are younger and they understand diagnosis. The food here is good and the program is very
accommodating. They like all the staff. They have calls with family two times a day. The groups here are helpful.
2
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
Observations
The program was in good repair. There are 23 cameras throughout campus. The current census is 13. During
sleeping hours, bed checks are completed every 15 minutes and randomly throughout the night. Staff are
required to check for signs of life during bed checks.
06.09.2021
Licensing Coordinator’s Signature: ________________________ Date: ___________________
Manager Review: ______________________________________ Date: ____6_-_8_-_2_0_2__1_ _____
3
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)

program_type: (RC) Residential Care Programs

report_type: Unannounced

view_code: RC

program_director: Michael Knapp

licensing_coordinator: Aubrey Kelly

purpose:
Per OAR 413-215-0101 (1) (b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings: Repeat Comments
License Renewal Site Visit 02-10-2021 Findings
Further Action
Needed
413-215-0061(1)(a) & (3)(c) Background Yes[ ] No Two background checks of recently promoted staff were reviewed and it was confirmed
check completed and documented: "One of new background checks were completed as required.
the files reviewed included staff who had
received a promotion and a new background
check had not been conducted per rule."
413-215-0546(2)(e) Documentation of age Yes[ ] No The nursing assessment that is completed when a client is admitted to the program was
appropriate instruction - pregnancy reviewed and the assessment contains the required information.
prevention, nutrition, prevention of HIV &
AIDS, and prevention and treatment of
sexually transmitted disease: "There was no
documentation of age appropriate instruction.
Madrona Recovery plans to add this to the
nursing assessment at intake so any concerns
around diet, pregnancy prevention, STDs, etc.
can be discussed with the nursing staff."
1

New Findings from Site Visit Comments
None
Interview Summary
Client #1: They have been at the program since May 21st. They were previously at another program and likes it
here better because this program teaches more coping skills. They feel safe here and have not had a time when
they felt unsafe. They get along with the other clients and staff. The food is good, they like the hamburger helper
and crepes. They see their therapist one time a week. They have calls with family two times a day and has virtual
visits with family on Saturdays and Sundays. They like the showers here and the beds are comfortable. They are
hoping to be discharged in 11 days.
Client #2: They have been at the program for one week. They previously had been at two different hospitals.
They like it here, it's much better than the hospital. Staff members here are in touch and knows how to deal with
mental health issues. After discharge, the plan is to go home. They feel safe here and have not had a time when
they felt unsafe. No one has placed their hands on them since admission. They get along well with staff, they like
the staff are younger and they understand diagnosis. The food here is good and the program is very
accommodating. They like all the staff. They have calls with family two times a day. The groups here are helpful.
2

Observations
The program was in good repair. There are 23 cameras throughout campus. The current census is 13. During
sleeping hours, bed checks are completed every 15 minutes and randomly throughout the night. Staff are
required to check for signs of life during bed checks.
06.09.2021

excerpt:
413-215-0546(2)(e) Documentation of age Yes[ ] No The nursing assessment that is completed when a client is admitted to the program was
appropriate instruction - pregnancy reviewed and the assessment contains the required information.
prevention, nutrition, prevention of HIV &
AIDS, and prevention and treatment of
sexually transmitted disease: "There was no
documentation of age appropriate instruction.
Madrona Recovery plans to add this to the
nursing assessment at intake so any concerns
around diet, pregnancy prevention, STDs, etc.
can be discussed with the nursing staff."
1
New Findings from Site Visit Comments
None
None


summary: Unannounced - 10/05/2022

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Madrona Recovery Inc
Executive Director: John Thornton
Program Director(s):
Date of Unannounced: 10/05/2022
Licensing Coordinator: Jeff Minden and Aubrey Kelly
Other Regulatory or Accrediting Agencies: OHA
Purpose: Per OAR 413-215-0101 (1) (b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Findings
Further Action
Needed
No outstanding findings from 2021 noted Yes☐ No☐
Yes☐ No☐
New Findings from Site Visit Comments
None
1
(rev. 200115)
Interview Summary
2 youth were interviewed during the site visit. Both youth reported liking Madrona Recovery better then other programs they had been at previously. Both
youth reported feeling safe in the program. One youth described Madrona Recovery as “just ok,” the food being ok, and wishing the beds were more
comfortable and that they had the ability to have community time outside the program. The other youth reported that the food is good, staff are nice and
supportive and that they feel like they are having the most success with their sobriety they have ever experienced. One of the youth reported a recent
negative interaction with 1 specific staff but reported that the rest of the program staff were very supportive and understanding and they felt the situation was
handled well by the program. Both youth were aware of their discharge plans and tentative discharge dates.
Observations
Facility was clean and in good repair. Random employee training files were reviewed, and trainings had been completed in a timely manner. Youth interviews
did not note any concerns.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Agency Name must submit a letter of verification indicating the agency is in compliance with the specific
rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency must submit any
and all specific documentation requested in the body of this report. The letter of verification and any additional requested documents can be emailed
directly to Licensing Coordinator email address.
Licensing Coordinator’s Signature: ________________________ Date: _____10/05/2022_____
Manager Review: ______________________________________ Date: _1_0_-_2_7_-_2_0_2_2_ _______
(rev. 07/21/2022)

licensee: Madrona Recovery Inc

executive_director: John Thornton

program_director: Date of Unannounced: 10/05/2022

licensing_coordinator: Jeff Minden and Aubrey Kelly

other_regulatory_agencies: OHA

purpose:
Per OAR 413-215-0101 (1) (b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Findings
Further Action
Needed
No outstanding findings from 2021 noted Yes[ ] No[ ]
Yes[ ] No[ ]
New Findings from Site Visit Comments
None
1

Interview Summary
2 youth were interviewed during the site visit. Both youth reported liking Madrona Recovery better then other programs they had been at previously. Both
youth reported feeling safe in the program. One youth described Madrona Recovery as "just ok," the food being ok, and wishing the beds were more
comfortable and that they had the ability to have community time outside the program. The other youth reported that the food is good, staff are nice and
supportive and that they feel like they are having the most success with their sobriety they have ever experienced. One of the youth reported a recent
negative interaction with 1 specific staff but reported that the rest of the program staff were very supportive and understanding and they felt the situation was
handled well by the program. Both youth were aware of their discharge plans and tentative discharge dates.
Observations
Facility was clean and in good repair. Random employee training files were reviewed, and trainings had been completed in a timely manner. Youth interviews
did not note any concerns.

new_findings:
None
1


summary: Unannounced - 9 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Care
Licensee: Madrona Recover
Executive Director: James Paul Bryant
Program Director(s): John Thornton (CEO)
Date of Unannounced: July 2, 2024
Licensing Coordinator: Jeff Minden, Irvin Minten
Other Regulatory or Accrediting Agencies: Oregon Health Authority
Purpose: Per OAR 419-400-0240 (1)(b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Unannounced Site Visit 10/23/2023 Findings
Further Action
Needed
419-400-0040(2)(g)– Board Approval of Yes☐ No✓ Board meeting minutes including budget approval were provided.
budget was not available for review
previously.
• This finding will be deferred to the
next reviews as the program has not
had any board meetings since the
licensing review in April. A board
meeting is scheduled for November.
419-400-0040(2)(k)- a written quality Yes☐ No✓ Board meeting minutes including quality improvement were provided.
improvement plan was not available for review
previously.
• This finding will be deferred to the
next reviews as the program has not
had any board meetings since the
licensing review in April. A board
meeting is scheduled for November.
Form Rev. 11/14/2023 P age 1 | 5
419-400-0040(2)(I)- board meeting minutes Yes☐ No✓ Board meeting minutes were provided.
was not available for review previously.
• This finding will be deferred to the
next reviews as the program has not
had any board meetings since the
licensing review in April. A board
meeting is scheduled for November.
419-470-0020(2)(a)(c) – A wall next to the Yes✓ No✓ The dining room wall was repaired, and the source of the buckle in the wall was addressed
dining room had started to buckle due to the as a part of a significant remodel at the program.
weight of a large water tank located in a
space behind the wall.
• This finding will be deferred to the
next review as the program is still in
the middle of a large renovation, and
the water tank fix is included in the
process.
419-400-0120(4)(c)(d)(g) 2 reviewed files did Yes☐ No✓ Reviewed files included all required trainings
not indicate ethics and professional guidelines
training, attributes of population served
training, and emergency procedure training
was received within 30 days of hire
• Reviewed files were missing the
attributes of populations served
training documentation, and 1 file was
missing the list of trainings. The
program did note that their usual HR
point person is on vacation and may
have the documentation in another
location, however it could not be
located today.
(repeat finding)
419-400-0180(12) and (13), 419-400-0190(1) Yes✓ No☐ Client files still lack documentation to verify parents and guardians were informed about
Specific information about reporting wrongful how to access quarterly restraint reports on the Madrona Recovery website.
restraint and seclusion was not being
provided as well as contact information for
entities required by rule. Additionally, the
program did not have a process for ensuring
parents/guardians receive notice of how to
access quarterly reports at intake.
• The program does have quarterly
restraint information available on their
website, however they have not
updated their documentation during
intake to include where to locate the
Form Rev. 11/14/2023 P age 2 | 5
quarterly report or how to report
concerns of wrongful restraint or
seclusion.
(repeat finding)
New Findings from Site Visit Comments
419-400-0200(4)(c): Each light fixture A light above a sink in the program’s art room did not have a protective cover.
must have a protective cover unless
it is designed to be used without one.
419-400-0090 (1) Rights of children The program has worked on allowing clients to make phone calls in private, and does have
in care and families served by the areas that can be utilized privately by clients. However, based on interviews with staff and
child-caring agency. A child-caring clients, it appears staff are still present in the room with clients during phone calls and do
agency must guarantee the rights of have the ability to listen in. The program needs to ensure a practice where clients are able
children in care and the families the to make phone calls without staff present and are aware of the option to do so.
child-caring agency serves. A child-
caring agency must enact and
adhere to a policy ensuring those
rights. A written copy must be
distributed to all children in care and
families served by the child-caring
agency, and afford the following
rights:
------
(b) The child in care's right to privacy.
Form Rev. 11/14/2023 P age 3 | 5
Interview Summary
3 staff were interviewed as a part of the site visit. All 3 staff were selected randomly and had roles including nurse, coordinator, and
case manager. All 3 staff stated they enjoyed working at the program, and although they said it is a hard job which takes a lot out of
you, it is also rewarding and satisfying. Two of the staff stated they enjoyed making a difference in the lives of youth. One of the
staff stated they very much enjoyed the creation of each youth’s individual treatment plan, as each youth’s plan was different and
focused on different strengths and areas needing improvement. All 3 staff also stated they received adequate to good initial and
ongoing training, although much of the job was learned by doing the work and getting regular feedback from other staff. All 3 staff
stated that if they had a question, there was always someone they could contact to get the answer. All 3 staff identified the high
turnover and burnout as the largest problem the program is facing in the past several months, as currently there is a high amount of
call-outs, and the program is also short staffed due to the turnover. One of the staff reported the staff training in the past 6 months
has not been as good as previous training, something they attributed to the fact that the program has lost some of their most
experienced line staff to promotions and turnover, resulting in some of the line staff feeling a lack of support and being
unappreciated. To improve the situation, this staff felt management staff should be more verbal in their acknowledgment of the
good work being done by the line staff, while also regularly communicating with all staff about the efforts being made to improve the
situation. Two of the staff were able to identify some of the management’s efforts to improve the situation. All 3 staff reported the
program had an effective process at the time of shift change, with sufficient time provided to talk about each of the youth’s current
issues and supervision needs. However, 1 of the staff stated the program used to have regular “mini-trainings,” or very brief
“refresher trainings” at the time of shift change focusing on de-escalation techniques, suicide prevention, etc., but over the last few
months, since the program is short staffed, these no longer occur. This staff felt such trainings were valuable and wanted them to
start up again. When asked if the program could improve in one area, 1 staff stated there was a lack of consistency in the way in
which staff on the same shift or staff on different shifts enforced the rules of the program, resulting in an increase in the anxiety of
the youth enrolled in the program, while making the job more difficult. Two of the staff stated the program needed to “have more
staff,” as currently staff are working too many hours, increasing their chance of burnout. All 3 staff stated the relationship between
line staff and management staff was good, and, for the most part, all staff could provide input on how to more effectively do the
work, and they felt listened to by management staff. When asked about whether the youth were able to have private phone calls,
one of the staff stated that youth knew that staff would be listening in on each of their phone calls, as the staff sat in close enough
proximity to the youth during phone calls to clearly hear what the youth was saying, and often staff could even hear what the person
on the other end of the line was saying. Another staff stated that although they could hear what the youth was talking about, they
really didn’t listen in to the calls. Finally, all 3 staff were able to effectively articulate the program’s suicide prevention protocol.
One youth was interviewed as a part of the unannounced visit. Although several youth were asked, only one was willing to be
interviewed. Youth reported being at the program for approximately 3 weeks and hating it. Youth later clarified that they didn’t hate
Madrona Recovery specifically but hated being at programs in general. Youth also noted that they had been to other programs in
Oregon and detention, and Madrona was the best location they had been to. Youth reported that some staff were “cool” and some
were on kids about the rules a lot more and “micro managed.” Youth also reported that they felt safe in the program, had never
been a part of or witness to a restraint, and that staff are consistent in their responses. Youth reported that staff are present during
Form Rev. 11/14/2023 P age 4 | 5
phone calls but they felt that staff weren’t actively trying to listen it. Youth reported knowing their discharge plan, and also wishing
that the program would reduce restrictions on MP3’s and makeup.
Observations
A site tour was conducted as a part of the Madrona Recovery unannounced visit. The program has recently completed an
extensive remodel and begun providing Psychiatric Residential Treatment Facility (PRTF) services. The facility was clean and in
good repair and has been well thought out for the new programs it is offering. There is art throughout the facility which helped with
the overall aesthetic of the facility.
In conversation with CEO John Thornton, he reported that the program is doing well. However, they have had issues with keeping
staff levels up, which is impacting their daily census. Thornton reported that the program has an extensive waiting list and has been
working on interviewing youth prior to admittance to ensure they are a good fit, but that they are working on hiring staff so they can
serve more clients.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Madrona Recovery must submit a letter of verification indicating the agency is in compliance with the
specific rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency must
submit any and all specific documentation requested in the body of this report. The letter of verification and any additional requested documents can
be emailed directly to Jeff Minden at Jeffrey.E.Minden@odhsoha.oregon.gov.
Licensing Coordinator’s Signature: ________________________ Date: ___0_7__-1_6_-_2_0_2_4_______
Manager Review: ______________________________________ Date: _7_-_1_6_-2__0_2_4_________
Form Rev. 11/14/2023 P age 5 | 5

facility_type: Residential Care

licensee: Madrona Recover

executive_director: James Paul Bryant

program_director: John Thornton (CEO)

licensing_coordinator: Jeff Minden, Irvin Minten

other_regulatory_agencies: Oregon Health Authority

purpose:
Per OAR 419-400-0240 (1)(b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Unannounced Site Visit 10/23/2023 Findings
Further Action
Needed
419-400-0040(2)(g)- Board Approval of Yes[ ] No✓ Board meeting minutes including budget approval were provided.
budget was not available for review
previously.
- This finding will be deferred to the
next reviews as the program has not
had any board meetings since the
licensing review in April. A board
meeting is scheduled for November.
419-400-0040(2)(k)- a written quality Yes[ ] No✓ Board meeting minutes including quality improvement were provided.
improvement plan was not available for review
previously.
- This finding will be deferred to the
next reviews as the program has not
had any board meetings since the
licensing review in April. A board
meeting is scheduled for November.

419-400-0040(2)(I)- board meeting minutes Yes[ ] No✓ Board meeting minutes were provided.
was not available for review previously.
- This finding will be deferred to the
next reviews as the program has not
had any board meetings since the
licensing review in April. A board
meeting is scheduled for November.
419-470-0020(2)(a)(c) - A wall next to the Yes✓ No✓ The dining room wall was repaired, and the source of the buckle in the wall was addressed
dining room had started to buckle due to the as a part of a significant remodel at the program.
weight of a large water tank located in a
space behind the wall.
- This finding will be deferred to the
next review as the program is still in
the middle of a large renovation, and
the water tank fix is included in the
process.
419-400-0120(4)(c)(d)(g) 2 reviewed files did Yes[ ] No✓ Reviewed files included all required trainings
not indicate ethics and professional guidelines
training, attributes of population served
training, and emergency procedure training
was received within 30 days of hire
- Reviewed files were missing the
attributes of populations served
training documentation, and 1 file was
missing the list of trainings. The
program did note that their usual HR
point person is on vacation and may
have the documentation in another
location, however it could not be
located today.
(repeat finding)
419-400-0180(12) and (13), 419-400-0190(1) Yes✓ No[ ] Client files still lack documentation to verify parents and guardians were informed about
Specific information about reporting wrongful how to access quarterly restraint reports on the Madrona Recovery website.
restraint and seclusion was not being
provided as well as contact information for
entities required by rule. Additionally, the
program did not have a process for ensuring
parents/guardians receive notice of how to
access quarterly reports at intake.
- The program does have quarterly
restraint information available on their
website, however they have not
updated their documentation during
intake to include where to locate the

quarterly report or how to report
concerns of wrongful restraint or
seclusion.
(repeat finding)
New Findings from Site Visit Comments
419-400-0200(4)(c): Each light fixture A light above a sink in the program's art room did not have a protective cover.
must have a protective cover unless
it is designed to be used without one.
419-400-0090 (1) Rights of children The program has worked on allowing clients to make phone calls in private, and does have
in care and families served by the areas that can be utilized privately by clients. However, based on interviews with staff and
child-caring agency. A child-caring clients, it appears staff are still present in the room with clients during phone calls and do
agency must guarantee the rights of have the ability to listen in. The program needs to ensure a practice where clients are able
children in care and the families the to make phone calls without staff present and are aware of the option to do so.
child-caring agency serves. A child-
caring agency must enact and
adhere to a policy ensuring those
rights. A written copy must be
distributed to all children in care and
families served by the child-caring
agency, and afford the following
rights:
------
(b) The child in care's right to privacy.

Interview Summary
3 staff were interviewed as a part of the site visit. All 3 staff were selected randomly and had roles including nurse, coordinator, and
case manager. All 3 staff stated they enjoyed working at the program, and although they said it is a hard job which takes a lot out of
you, it is also rewarding and satisfying. Two of the staff stated they enjoyed making a difference in the lives of youth. One of the
staff stated they very much enjoyed the creation of each youth's individual treatment plan, as each youth's plan was different and
focused on different strengths and areas needing improvement. All 3 staff also stated they received adequate to good initial and
ongoing training, although much of the job was learned by doing the work and getting regular feedback from other staff. All 3 staff
stated that if they had a question, there was always someone they could contact to get the answer. All 3 staff identified the high
turnover and burnout as the largest problem the program is facing in the past several months, as currently there is a high amount of
call-outs, and the program is also short staffed due to the turnover. One of the staff reported the staff training in the past 6 months
has not been as good as previous training, something they attributed to the fact that the program has lost some of their most
experienced line staff to promotions and turnover, resulting in some of the line staff feeling a lack of support and being
unappreciated. To improve the situation, this staff felt management staff should be more verbal in their acknowledgment of the
good work being done by the line staff, while also regularly communicating with all staff about the efforts being made to improve the
situation. Two of the staff were able to identify some of the management's efforts to improve the situation. All 3 staff reported the
program had an effective process at the time of shift change, with sufficient time provided to talk about each of the youth's current
issues and supervision needs. However, 1 of the staff stated the program used to have regular "mini-trainings," or very brief
"refresher trainings" at the time of shift change focusing on de-escalation techniques, suicide prevention, etc., but over the last few
months, since the program is short staffed, these no longer occur. This staff felt such trainings were valuable and wanted them to
start up again. When asked if the program could improve in one area, 1 staff stated there was a lack of consistency in the way in
which staff on the same shift or staff on different shifts enforced the rules of the program, resulting in an increase in the anxiety of
the youth enrolled in the program, while making the job more difficult. Two of the staff stated the program needed to "have more
staff," as currently staff are working too many hours, increasing their chance of burnout. All 3 staff stated the relationship between
line staff and management staff was good, and, for the most part, all staff could provide input on how to more effectively do the
work, and they felt listened to by management staff. When asked about whether the youth were able to have private phone calls,
one of the staff stated that youth knew that staff would be listening in on each of their phone calls, as the staff sat in close enough
proximity to the youth during phone calls to clearly hear what the youth was saying, and often staff could even hear what the person
on the other end of the line was saying. Another staff stated that although they could hear what the youth was talking about, they
really didn't listen in to the calls. Finally, all 3 staff were able to effectively articulate the program's suicide prevention protocol.
One youth was interviewed as a part of the unannounced visit. Although several youth were asked, only one was willing to be
interviewed. Youth reported being at the program for approximately 3 weeks and hating it. Youth later clarified that they didn't hate
Madrona Recovery specifically but hated being at programs in general. Youth also noted that they had been to other programs in
Oregon and detention, and Madrona was the best location they had been to. Youth reported that some staff were "cool" and some
were on kids about the rules a lot more and "micro managed." Youth also reported that they felt safe in the program, had never
been a part of or witness to a restraint, and that staff are consistent in their responses. Youth reported that staff are present during

phone calls but they felt that staff weren't actively trying to listen it. Youth reported knowing their discharge plan, and also wishing
that the program would reduce restrictions on MP3's and makeup.
Observations
A site tour was conducted as a part of the Madrona Recovery unannounced visit. The program has recently completed an
extensive remodel and begun providing Psychiatric Residential Treatment Facility (PRTF) services. The facility was clean and in
good repair and has been well thought out for the new programs it is offering. There is art throughout the facility which helped with
the overall aesthetic of the facility.
In conversation with CEO John Thornton, he reported that the program is doing well. However, they have had issues with keeping
staff levels up, which is impacting their daily census. Thornton reported that the program has an extensive waiting list and has been
working on interviewing youth prior to admittance to ensure they are a good fit, but that they are working on hiring staff so they can
serve more clients.


summary: Unannounced - 5 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Care
Licensee: Madrona Recovery
Executive Director: James Paul Bryant
Program Director(s): Paul Bryant
Date of Unannounced: 03/04/2025
Licensing Coordinator: Jeff Minden
Other Regulatory or Accrediting Agencies: Oregon Health Authority
Purpose: Per OAR 419-400-0240 (1)(b) Children’s Care Licensing is required to perform at least one unannounced site visit a year
where children in care reside.
Previous Findings Repeat Comments
Unannounced Site Visit – 7/02/2024 Findings
Further Action
Needed
419-400-0180(12) and (13), 419-400-0190(1) Yes☐ No✓ Intake forms have been updated to include information on
Specific information about reporting wrongful how to find quarterly reports.
restraint and seclusion was not being provided as
well as contact information for
entities required by rule. Additionally, the
program did not have a process for ensuring
parents/guardians receive notice of how to
access quarterly reports at intake.
• The program does have quarterly restraint
information available on their website, however
they have not updated their documentation during
intake to include where to locate the quarterly
Form Rev. 11/14/2023 P age 1 | 5
report or how to report concerns of wrongful
restraint or seclusion.
(repeat finding)
• Client files still lack documentation to verify
parents and guardians were informed about
how to access quarterly restraint reports on
the Madrona Recovery website.
419-400-0200(4)(c): Each light fixture must have a Yes☐ No✓ The light fixture has a protective cover now.
protective cover unless it is designed to be used
without one.
• A light above a sink in the program’s art
room did not have a protective cover.
419-400-0090 (1) Rights of children in care and Yes☐ No✓ The program reported that youth are allowed to make phone
families served by the child-caring agency. A calls alone in rooms. Staff will watch via video without
child-caring agency must guarantee the rights of sound for safety. Client interviews confirmed they are
children in care and the families the child-caring allowed to make phone calls without staff present.
agency serves. A child-caring agency must enact
and adhere to a policy ensuring those rights. A
written copy must be distributed to all children in
care and families served by the child-caring
agency, and afford the following rights: ------
(b) The child in care's right to privacy.
• The program has worked on allowing
clients to make phone calls in private and
does have areas that can be utilized
privately by clients. However, based on
interviews with staff and clients, it appears
staff are still present in the room with
clients during phone calls and do have the
ability to listen in. The program needs to
ensure a practice where clients are able to
make phone calls without staff present and
are aware of the option to do so.
Form Rev. 11/14/2023 P age 2 | 5
New Findings from Site Visit Comments
419-400-0230(2) Adhere to and comply with all Concerns were noted that Madrona Recovery was not meeting minimum
policies and procedures of the licensee and staffing requirements that the program has established to comply with OHA
ensures that employees and volunteers comply rule requirements. Multiple staff reported that the program is routinely out of
with policies and procedures compliance with staffing levels.
Interview Summary
3 staff and 3 youth were interviewed as a part of the unannounced site visit. All 3 interviewed youth reported feeling safe in the
program, reported liking staff and feeling like they could approach them for support. 2 of the interviewed youth reported being at
similar programs previously in other states and stated that Madrona Recovery was better than other locations they had been to. 2
of the 3 clients reported that the food was excellent, and 1 wished that there was more variety (and specifically wished for Carne
Asada on the menu). The clients were able to name specific staff they preferred and trusted to reach out to, including Kennedy,
Karli, Brittany, Taylor, Cici, May and Tashe. Clients all reported being aware of the discharge planning for their case and being able
to make phone calls privately. One client reported a concern about an incident that had occurred approximately 2 weeks prior
between a staff and a youth that resulted in a physical altercation. This concern was forwarded to Madrona staff who were able to
find documentation about the report and called the report in for screening and investigation.
3 staff were also interviewed as a part of the review process. Staff were consistent in feeling like their supervisors supported them,
and one staff specifically mention the new Executive Director, Paul, had been a great addition to the program. All 3 staff separately
noted concerns about staffing levels and having to meet required ratios. Reports indicated that ratios were out of compliance at
least twice a week if not more, and one staff reported that they had been supervising 6-7 clients alone from 7am to approximately
830am. Interviewed staff indicated that both nurses and managers are being used to cover floor staff requirements, and that nurses
are then not able to complete their nursing duties. It was additionally reported that managers will just stay in the fishbowl and not
assist with floor duties despite being counted towards ratios.
Interviewed staff also reported clients are not being held accountable for their behaviors, and one staff characterized the clients
being able to do anything they want and the clients are “running the show.” Staff described clients being able to stay in bed all day
if they wished as an example. Multiple staff reported feeling uncomfortable with CPI, restraints, and de-escalation training and
Form Rev. 11/14/2023 P age 3 | 5
knowing what to do. It was noted by one of the interviewed staff that there had been an intent for staff to practice CPI at the end of
shifts, so that those hours could be counted towards certification, however the staff did not know if the CPI trainers would be
conducting the training or if it would just be floor staff practicing together.
Two staff talked about the program utilizing a program called “Focus” for addressing client behaviors; however, neither staff was
able to articulate what “Focus” was or how it was supposed to be implemented. Staff reported that training, both initial and ongoing,
was unclear and unhelpful. One staff specifically reported not feeling like the suicide prevention training gave them the skills to
address suicidal ideation. Another staff indicated that they wished that the program would better cover de-escalation training and
removing glass from clients when its being used for self-harm. One staff indicated that some clients can be very difficult to work
with to the point they are afraid to approach them.
One staff also noted concerns that management may be watching and listening in during the interview with OTIS staff. This licensor
also heard from an OTIS Investigator with an open investigation at Madrona that they had learned from a different staff member that
Madrona management had been observing OTIS investigation interviews through the camera system which allowed for audio and
video observation.
Observations
The program appeared clean and in good repair. Bedrooms, bathrooms, and common areas were not cluttered and well organized.
CCLP followed up with Madrona management about the reported concern that OTIS interviews are being observed through the
video system by management staff. Management noted that the Summit Room is where most interviews occur, and that the camera
had been removed from the room. All OTIS interviews should be conducted in this room.
Recommendation:
It is recommended that Madrona Recovery management review the training process and work with staff to ensure they are informed
and comfortable handling situations that may arise at the program. Additionally, its recommended that management work to ensure
the “Focus” program is clear to staff in its purpose and function. Management staff have noted since the interview that the program
has several trainings scheduled about the “Focus” program and its function and intent.
Corrective Actions and Timeframes:
Form Rev. 11/14/2023 P age 4 | 5
Please submit the following to verify compliance.
Within 45 days of receipt of this report Madrona Recovery must submit a letter of verification indicating the agency is in compliance
with the specific rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification,
the agency must submit any and all specific documentation requested in the body of this report. The letter of verification and any
additional requested documents can be emailed directly to Jeff Minden at Jeffrey.E.Minden@odhsoha.oregon.gov.
Licensing Coordinator’s Signature: ________________________ Date: _3_/1_2_/_2_0_2_5___________
Manager Review: ______________________________________ Date: _3_-1_2_-_2_0_2_5__________
Form Rev. 11/14/2023 P age 5 | 5

program_director: Paul Bryant

licensing_coordinator: Jeff Minden

purpose:
Per OAR 419-400-0240 (1)(b) Children's Care Licensing is required to perform at least one unannounced site visit a year
where children in care reside.
Previous Findings Repeat Comments
Unannounced Site Visit - 7/02/2024 Findings
Further Action
Needed
419-400-0180(12) and (13), 419-400-0190(1) Yes[ ] No✓ Intake forms have been updated to include information on
Specific information about reporting wrongful how to find quarterly reports.
restraint and seclusion was not being provided as
well as contact information for
entities required by rule. Additionally, the
program did not have a process for ensuring
parents/guardians receive notice of how to
access quarterly reports at intake.
- The program does have quarterly restraint
information available on their website, however
they have not updated their documentation during
intake to include where to locate the quarterly

report or how to report concerns of wrongful
restraint or seclusion.
(repeat finding)
- Client files still lack documentation to verify
parents and guardians were informed about
how to access quarterly restraint reports on
the Madrona Recovery website.
419-400-0200(4)(c): Each light fixture must have a Yes[ ] No✓ The light fixture has a protective cover now.
protective cover unless it is designed to be used
without one.
- A light above a sink in the program's art
room did not have a protective cover.
419-400-0090 (1) Rights of children in care and Yes[ ] No✓ The program reported that youth are allowed to make phone
families served by the child-caring agency. A calls alone in rooms. Staff will watch via video without
child-caring agency must guarantee the rights of sound for safety. Client interviews confirmed they are
children in care and the families the child-caring allowed to make phone calls without staff present.
agency serves. A child-caring agency must enact
and adhere to a policy ensuring those rights. A
written copy must be distributed to all children in
care and families served by the child-caring
agency, and afford the following rights: ------
(b) The child in care's right to privacy.
- The program has worked on allowing
clients to make phone calls in private and
does have areas that can be utilized
privately by clients. However, based on
interviews with staff and clients, it appears
staff are still present in the room with
clients during phone calls and do have the
ability to listen in. The program needs to
ensure a practice where clients are able to
make phone calls without staff present and
are aware of the option to do so.

New Findings from Site Visit Comments
419-400-0230(2) Adhere to and comply with all Concerns were noted that Madrona Recovery was not meeting minimum
policies and procedures of the licensee and staffing requirements that the program has established to comply with OHA
ensures that employees and volunteers comply rule requirements. Multiple staff reported that the program is routinely out of
with policies and procedures compliance with staffing levels.
Interview Summary
3 staff and 3 youth were interviewed as a part of the unannounced site visit. All 3 interviewed youth reported feeling safe in the
program, reported liking staff and feeling like they could approach them for support. 2 of the interviewed youth reported being at
similar programs previously in other states and stated that Madrona Recovery was better than other locations they had been to. 2
of the 3 clients reported that the food was excellent, and 1 wished that there was more variety (and specifically wished for Carne
Asada on the menu). The clients were able to name specific staff they preferred and trusted to reach out to, including Kennedy,
Karli, Brittany, Taylor, Cici, May and Tashe. Clients all reported being aware of the discharge planning for their case and being able
to make phone calls privately. One client reported a concern about an incident that had occurred approximately 2 weeks prior
between a staff and a youth that resulted in a physical altercation. This concern was forwarded to Madrona staff who were able to
find documentation about the report and called the report in for screening and investigation.
3 staff were also interviewed as a part of the review process. Staff were consistent in feeling like their supervisors supported them,
and one staff specifically mention the new

interview_summary:
3 staff and 3 youth were interviewed as a part of the unannounced site visit. All 3 interviewed youth reported feeling safe in the
program, reported liking staff and feeling like they could approach them for support. 2 of the interviewed youth reported being at
similar programs previously in other states and stated that Madrona Recovery was better than other locations they had been to. 2
of the 3 clients reported that the food was excellent, and 1 wished that there was more variety (and specifically wished for Carne
Asada on the menu). The clients were able to name specific staff they preferred and trusted to reach out to, including Kennedy,
Karli, Brittany, Taylor, Cici, May and Tashe. Clients all reported being aware of the discharge planning for their case and being able
to make phone calls privately. One client reported a concern about an incident that had occurred approximately 2 weeks prior
between a staff and a youth that resulted in a physical altercation. This concern was forwarded to Madrona staff who were able to
find documentation about the report and called the report in for screening and investigation.
3 staff were also interviewed as a part of the review process. Staff were consistent in feeling like their supervisors supported them,
and one staff specifically mention the new Executive Director, Paul, had been a great addition to the program. All 3 staff separately
noted concerns about staffing levels and having to meet required ratios. Reports indicated that ratios were out of compliance at
least twice a week if not more, and one staff reported that they had been supervising 6-7 clients alone from 7am to approximately
830am. Interviewed staff indicated that both nurses and managers are being used to cover floor staff requirements, and that nurses
are then not able to complete their nursing duties. It was additionally reported that managers will just stay in the fishbowl and not
assist with floor duties despite being counted towards ratios.
Interviewed staff also reported clients are not being held accountable for their behaviors, and one staff characterized the clients
being able to do anything they want and the clients are "running the show." Staff described clients being able to stay in bed all day
if they wished as an example. Multiple staff reported feeling uncomfortable with CPI, restraints, and de-escalation training and

knowing what to do. It was noted by one of the interviewed staff that there had been an intent for staff to practice CPI at the end of
shifts, so that those hours could be counted towards certification, however the staff did not know if the CPI trainers would be
conducting the training or if it would just be floor staff practicing together.
Two staff talked about the program utilizing a program called "Focus" for addressing client behaviors; however, neither staff was
able to articulate what "Focus" was or how it was supposed to be implemented. Staff reported that training, both initial and ongoing,
was unclear and unhelpful. One staff specifically reported not feeling like the suicide prevention training gave them the skills to
address suicidal ideation. Another staff indicated that they wished that the program would better cover de-escalation training and
removing glass from clients when its being used for self-harm. One staff indicated that some clients can be very difficult to work
with to the point they are afraid to approach them.
One staff also noted concerns that management may be watching and listening in during the interview with OTIS staff. This licensor
also heard from an OTIS Investigator with an open investigation at Madrona that they had learned from a different staff member that
Madrona management had been observing OTIS investigation interviews through the camera system which allowed for audio and
video observation.

observations:
The program appeared clean and in good repair. Bedrooms, bathrooms, and common areas were not cluttered and well organized.
CCLP followed up with Madrona management about the reported concern that OTIS interviews are being observed through the
video system by management staff. Management noted that the Summit Room is where most interviews occur, and that the camera
had been removed from the room. All OTIS interviews should be conducted in this room.
Recommendation:
It is recommended that Madrona Recovery management review the training process and work with staff to ensure they are informed
and comfortable handling situations that may arise at the program. Additionally, its recommended that management work to ensure
the "Focus" program is clear to staff in its purpose and function. Management staff have noted since the interview that the program
has several trainings scheduled about the "Focus" program and its function and intent.