summary: Unannounced - 12 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Program
Licensee: The Next Door, Inc – Klahre House Residential
Treatment Program
Executive Director: Janet Hamada
Program Director(s): Melanie Kelly
Date of Unannounced: 10-1-24
Licensing Coordinator: Irvin Minten, M.S.W.
Other Regulatory or Accrediting Agencies: Oregon Department of Human Services (ODHS) Treatment Services and Oregon
Youth Authority (OYA)
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
License Renewal Site Visit Findings
11/01/23 Further
Action
Needed
Physical Plant. 419-470- Yes☐ No✓ During walkthrough of the program, the program was found to be
0020(2)(a) &(c). Buildings are very clean and in good repair. Youth enrolled in the program
smoke free, clean and in good assist in cleaning the program on a twice a week basis.
repair.
• Although the program
was found to be in good
repair, well-kept and
Form Rev. 11/14/2023 P age 1 | 15
clean, there was some
mold in one of the
youth’s showers where
the youth’s shampoo
was kept. The program
must ensure there is not
any mold in the youth’s
showers.
Residential Care Safety Yes☐ No✓ The program’s monthly fire drill log was observed, and the log
419-470-0080(5)(a). An contained all required fields. In addition, the program was found
evacuation drill occurs to be having monthly fire drills and the fire drill log was being fully
monthly under varying completed.
conditions, is retained 2 years
and contains:
(A) identify of person
conducting drill
(B) date & time
(C) notification method
(D) staff participating
(E) # of children & staff
evacuated
(F) special conditions
simulated
(G) problems encountered
(H) time to complete
• Since the program
opened, the program has
not been having monthly
evacuation drills as, to
date, the program has
documented only 2 drills,
Form Rev. 11/14/2023 P age 2 |
15
in September and
October 2023. In
addition, the program’s
fire drill log does not
contain all required
fields AND staff are
sometimes not
completing the required
fields on the form.
These fields include: (A)
Identity of person
conducting drill; (D) Staff
participating; and (C)
Problems encountered.
The program must
ensure that monthly
evacuation drills are
occurring, that their
evacuation drill log
contains all required
fields, and that the
evacuation drill log is
being fully completed by
staff.
Medication 419-470-0100(7)(c). Yes No✓ The program’s medications are kept in a locked metal storage
Medications are inaccessible cabinet in one of the main living areas of the house. In addition,
to children and stored behind the medications are now also kept in a locked storage compartment
at least two locking within the locked metal storage cabinet; thus, they are now stored
mechanisms. This does not behind two locking mechanisms.
apply to Naloxone.
Form Rev. 11/14/2023 P age 3 |
15
• The children’s
medications are
currently kept in a locked
metal storage cabinet
and the metal storage
cabinet is in one of the
main living areas of the
house. The program
must ensure that
medications are stored
behind at least two
locking mechanisms.
Medication. 419-470-0100(10). Yes☐ No✓ During the unannounced site review, a child’s MAR was randomly
Written record of the selected and observed. All required fields of the child’s MAR were
administration of medication completed including a description of the medication and the
includes: possible adverse reactions to the medication, as noted on the
(a) name prescription bottle, that the child may experience.
(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.
• The program’s MAR
contains all required
fields. However, all
required fields are not
being completed. These
Form Rev. 11/14/2023 P age 4 |
15
fields include: (b)
description of the
medication; and (h)
possible adverse
reactions. The program
must ensure that staff
are fully completing each
child’s MAR.
Consents. 419-470-0160(1)(e). Yes☐ No✓ The program now has a consent stating that the program will allow
Allow access as defined in access as defined in 419-400-0230 and 0240. This consent is
419-400-0230 & 0240. reviewed and signed by the youth’s parent or guardian at the
• The program does not youth’s intake meeting into the program.
have a consent stating
that the program will
allow access as defined
in 419-400-0230 and
0240. The program must .
have a consent stating
that the program will
allow access as defined
in 419-400-0230 and
0240.
Consents. 419-470-0160(1)(g). Yes☐ No✓ The program now has a consent that the program will apply the
Apply the reasonable and reasonable and prudent parent standard. This consent is reviewed
prudent parent standard. and signed by the youth’s parent or guardian at the intake meeting
• The program does not of a youth into the program.
have a consent that it
will apply the reasonable
and prudent parent
standard. The program
must have a consent that
Form Rev. 11/14/2023 P age 5 |
15
it will apply the
reasonable and prudent
parent standard.
Disclosures. 419-470- Yes☐ No✓ The program now has a disclosure regarding personal and room
0160(2)(a). searches and protocols for confiscation of contraband. This
Parent/guardian has disclosure is reviewed and signed by the youth’s parent or
acknowledged in writing: guardian at the intake meeting of a youth into the program.
Information regarding
personal or room searches
and protocols for confiscation
of contraband.
• The program does not
have a disclosure
regarding personal or
room searches and
protocols for
confiscation of
contraband. The
program must have a
disclosure regarding
personal or room
searches and protocols
for confiscation of
contraband.
Authorizations. 419-470- Yes☐ No✓ The program now has an authorization that all visitation resources
0160(3)(c). Visitation must be pre-approved. This authorization is reviewed and signed
resources are pre-approved. by the youth’s parent or guardian at the intake meeting of a youth
• Although the program is into the program.
documenting approved
visitation resources for
each youth in the
Form Rev. 11/14/2023 P age 6 |
15
program, the program
does not have an
authorization that all
visitation resources
must be pre-approved.
The program must
ensure that they have an
authorization that all
visitation resources
must be pre-approved.
Authorizations. 419-470- Yes☐ No✓ The program now has an activity specific authorization that
0160(3)(d). Activity specific ensures that all potentially hazardous activities in which children
authorizations are pre- in care may participate in while enrolled in the program are pre-
approved to allow children to approved. This authorization is reviewed and signed by the
participate in potentially youth’s parent or guardian at the intake meeting of a youth into
hazardous activities, including the program.
but not limited to using
motorized yard equipment,
swimming, and horseback
riding.
• The program does not
have a pre-approved
authorization to allow
children to participate in
potentially hazardous
activities, including but
not limited to hiking or
using motorized yard
equipment such as
lawnmowers. The
program must have a
Form Rev. 11/14/2023 P age 7 |
15
pre-approved
authorization to allow
children to participate in
potentially hazardous
activities including but
not limited to hiking or
using a motorized lawn
mower.
Information about Children in Yes☐ No✓ The program’s summary sheet now contains the name, gender,
Care. 419-400-0190(1)(a). date of birth, religious preference, and previous address of the
Summary sheet contains the child. This summary sheet is contained in the child file of each
following: (a)The name, child enrolled in the program.
gender, date of birth, religious
preference, and previous
address.
• The program’s summary
sheet does not include
an area to list the
previous address for the
child. Also, although the
program’s summary
sheet includes an area to
document a child’s
religious preference, the
program’s staff are not
providing documentation
in the allowed area. The
program’s summary
sheet must include an
area to indicate the
child’s previous address
Form Rev. 11/14/2023 P age 8 |
15
and the program’s staff
must complete all
required fields on the
program’s summary
sheet, including the
child’s religious
preference, if applicable.
Information about Children in Yes☐ No✓ The program’s summary sheet on each child now includes an area
Care. 419-400-0190(1)(e). to list other professionals to be involved in service planning, if
Summary sheet contains the applicable. The program must also ensure that staff are
following: (e) The name, completing all required fields on the child’s summary sheet.
address, and telephone
number of:
(A) The child in care's
parents.
(B) The child in care's legal
guardian, if different than
the parents, and a copy of
the document that provides
for his or her authority over
the child in care.
(C) Other persons
significant to child
(D) Other professionals to
be involved in service
planning (if applicable).
• The program’s summary
sheet does not include
an area to list (c) Other
professionals to be
involved in service
Form Rev. 11/14/2023 P age 9 |
15
planning (if applicable).
The program’s summary
sheet must include an
area to list other
professionals to be
involved in service
planning (if applicable).
Case Management. 419-470- Yes☐ No✓ The program’s discharge summaries now include all required
0170(3)(c)(A-G). Discharge fields.
summary must include:
(A)Current medications
(B)Name of the physician or
qualified medical professional
who prescribed each
medication
(C)Any outstanding medical or
other appointments
(D)Summary of the child’s
participation in the program
and progress achieved
(E)Results of evaluations
(F)Recommendations
regarding services
(G)Discharge destination.
• The program’s discharge
summaries do not
include all required
information. The
program’s discharge
summaries do not
include (A) Current
Form Rev. 11/14/2023 P age 10 |
15
medications of child; (B)
Name of the physician or
qualified medical
professional who
prescribed each
medication; (C) Any
outstanding medical or
other appointments; and
(E) Results of
evaluations. The
program’s discharge
summaries must include
all required information.
Records Relating to Restraint Yes☐ No✓ The program is now providing notice regarding how to access the
& Involuntary Seclusion. 419- quarterly reports to the parents or guardians of children in care.
400-0180(13)(e). Each child This notice is being provided at the time of a child in care’s intake
caring agency shall provide meeting into the program and is also being provided on the
notice regarding how to children in care’s Initial and On-Going Treatment Plans.
access the quarterly reports to
the parents or guardians of
children in care in the
program. The child caring
agency shall provide the
notice upon the child in care’s
admission and at least two
times each year thereafter.
• The program is not
providing notice
regarding how to access
the quarterly restraint
reports to the parents or
Form Rev. 11/14/2023 P age 11 |
15
guardians of children in
the program. The
program must ensure
they are providing notice
regarding how to access
the quarterly restraint
report to the parents or
guardians of children in
the program. The
program shall provide
the notice upon the
child.
Financial Records. 419-470- Yes☐ No✓ The program is now maintaining an updated financial record for
0170(4). Financial records each child in care in the program. The program’s financial record
contain date, amount, source, form also includes all required fields.
purpose, signatures.
• The program is not
maintaining an updated
financial record for each
youth in the program.
The program’s financial
record form also does
not include all required
fields, or the financial
record form is not being
fully completed. The
program must ensure
that each youth in the
program has an updated
financial record and that
the program’s financial
Form Rev. 11/14/2023 P age 12 |
15
record form contains all
required fields and that
all required fields are
being fully completed by
program staff.
Personal Possessions Yes☐ No✓ The program is now maintaining an individual written inventory
Records. 419-470-0170 (5). for each child in care of all personal possessions and this inventory
Individual written inventory of is being updated, as needed.
all personal possessions is
maintained and updated as
needed.
• The program is not
maintaining an updated
written inventory of each
child’s personal
possessions. The
program must ensure
they are maintaining an
updated personal
possessions inventory
for each child in the
program.
New Findings from Site Visit Comments
There were not any new findings
from the site visit.
Form Rev. 11/14/2023 P age 13 |
15
Interview Summary
During the unannounced site review, a good deal of discussion took place with Poe Foster, Program Manager and with Asia
Van Horn, supervisor of the Klahre House Residential Program. Shortly after the site visit, I was also able to have a
telephone conversation with Melanie Kelly, Program Director. In addition, two youth enrolled in the Klahre House
Residential Program and one staff of the program were randomly selected and individually interviewed. The staff person
was interviewed via the telephone.
One of the youth enrolled in the residential program stated the program was “nice,” that the program was a “homelike
setting,” that the food was “pretty good,’ and that they went on lots of outings in the community. The other youth stated he
“liked living in the program,” that he had his own room, that the food was OK, and that he was learning a great deal in the
program, especially in his gardening and culinary classes. He also stated he liked the program more than other programs he
had previously been enrolled since he had his own room. Both youth stated that staff were helpful and nice. When asked if
they would change anything about the program, one of the youth could not think of anything they would change and the
other wished the program would provide him with “more free time” and he wished the program would allow him to call and
talk with old friends. This youth also stated he wished his Probation Officer didn’t take so long to approve visits with his
family members outside of the program. Both youth also stated they felt safe in the program both during the day and at
night while in their bedrooms, and both youth reported they were able to make private calls when they wanted to persons on
their approved contact list. Both youth also denied ever being treated badly or observing anotheryouth in the program being
treated badly in any way by program staff.
During telephonic interview with the one line staff, we discussed his duties as a Youth Care Specialist. He stated he enjoys
working for the agency and feels supported in his role. He also stated he always has someone to call, if he were to have a
question and stated the culture of the program is welcoming to everyone, is positive, and is supportive. He also stated he
receives enough information about each child to effectively address their treatment issues and keep them safe and was able
to talk about systems the program had in place to effectively keep staff updated about youth’s behaviors and critical
information about new admits into the program. He also stated he felt he received sufficient training and was able to
effectively relay the program’s suicide prevention and search policies and stated he had his annual suicide prevention
training coming up in the next week. Finally, he stated his supervisor had discussions with him about suicide prevention,
medication administration, and search, as appropriate and when issues came up.
Form Rev. 11/14/2023 P age 14 |
15
Observations
During walkthrough of the program, it was observed that the house was in a well-maintained middle-class neighborhood and
that the house was well-constructed and designed, with main living and outdoor areas which were well maintained,
welcoming, and in good repair. The bathrooms and kitchen also had very nice appliances and fixtures, and most of the
showers were nicely tiled. The areas where youth congregated were also nicely painted and included comfortable and nice
furniture. The residence was also very clean. The main living area of the program had a vaulted ceiling, with the kitchen
directly attached. The kitchen also had a nice pantry.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report The Next Door 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 Irvin Minten at
Irvin.minten@odhsoha.oregon.gov.
Licensing Coordinator’s Signature: ________________________ Date: ___________________
10-17-2024
Manager Review: ______________________________________ Date: ___1_0_-_1_6_-2_0_2_4_______
Form Rev. 11/14/2023 P age 15 |
15

report_type: Unannounced

facility_type: Residential Program

licensee: The Next Door, Inc - Klahre House Residential Treatment Program

executive_director: Janet Hamada

program_director: Melanie Kelly

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
License Renewal Site Visit Findings
11/01/23 Further
Action
Needed
Physical Plant. 419-470- Yes[ ] No✓ During walkthrough of the program, the program was found to be
0020(2)(a) &(c). Buildings are very clean and in good repair. Youth enrolled in the program
smoke free, clean and in good assist in cleaning the program on a twice a week basis.
repair.
- Although the program
was found to be in good
repair, well-kept and

clean, there was some
mold in one of the
youth's showers where
the youth's shampoo
was kept. The program
must ensure there is not
any mold in the youth's
showers.
Residential Care Safety Yes[ ] No✓ The program's monthly fire drill log was observed, and the log
419-470-0080(5)(a). An contained all required fields. In addition, the program was found
evacuation drill occurs to be having monthly fire drills and the fire drill log was being fully
monthly under varying completed.
conditions, is retained 2 years
and contains:
(A) identify of person
conducting drill
(B) date & time
(C) notification method
(D) staff participating
(E) # of children & staff
evacuated
(F) special conditions
simulated
(G) problems encountered
(H) time to complete
- Since the program
opened, the program has
not been having monthly
evacuation drills as, to
date, the program has
documented only 2 drills,

15
in September and
October 2023. In
addition, the program's
fire drill log does not
contain all required
fields AND staff are
sometimes not
completing the required
fields on the form.
These fields include: (A)
Identity of person
conducting drill; (D) Staff
participating; and (C)
Problems encountered.
The program must
ensure that monthly
evacuation drills are
occurring, that their
evacuation drill log
contains all required
fields, and that the
evacuation drill log is
being fully completed by
staff.
Medication 419-470-0100(7)(c). Yes No✓ The program's medications are kept in a locked metal storage
Medications are inaccessible cabinet in one of the main living areas of the house. In addition,
to children and stored behind the medications are now also kept in a locked storage compartment
at least two locking within the locked metal storage cabinet; thus, they are now stored
mechanisms. This does not behind two locking mechanisms.
apply to Naloxone.

15
- The children's
medications are
currently kept in a locked
metal storage cabinet
and the metal storage
cabinet is in one of the
main living areas of the
house. The program
must ensure that
medications are stored
behind at least two
locking mechanisms.
Medication. 419-470-0100(10). Yes[ ] No✓ During the unannounced site review, a child's MAR was randomly
Written record of the selected and observed. All required fields of the child's MAR were
administration of medication completed including a description of the medication and the
includes: possible adverse reactions to the medication, as noted on the
(a) name prescription bottle, that the child may experience.
(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.
- The program's MAR
contains all required
fields. However, all
required fields are not
being completed. These

15
fields include: (b)
description of the
medication; and (h)
possible adverse
reactions. The program
must ensure that staff
are fully completing each
child's MAR.
Consents. 419-470-0160(1)(e). Yes[ ] No✓ The program now has a consent stating that the program will allow
Allow access as defined in access as defined in 419-400-0230 and 0240. This consent is
419-400-0230 & 0240. reviewed and signed by the youth's parent or guardian at the
- The program does not youth's intake meeting into the program.
have a consent stating
that the program will
allow access as defined
in 419-400-0230 and
0240. The program must .
have a consent stating
that the program will
allow access as defined
in 419-400-0230 and
0240.
Consents. 419-470-0160(1)(g). Yes[ ] No✓ The program now has a consent that the program will apply the
Apply the reasonable and reasonable and prudent parent standard. This consent is reviewed
prudent parent standard. and signed by the youth's parent or guardian at the intake meeting
- The program does not of a youth into the program.
have a consent that it
will apply the reasonable
and prudent parent
standard. The program
must have a consent that

15
it will apply the
reasonable and prudent
parent standard.
Disclosures. 419-470- Yes[ ] No✓ The program now has a disclosure regarding personal and room
0160(2)(a). searches and protocols for confiscation of contraband. This
Parent/guardian has disclosure is reviewed and signed by the youth's parent or
acknowledged in writing: guardian at the intake meeting of a youth into the program.
Information regarding
personal or room searches
and protocols for confiscation
of contraband.
- The program does not
have a disclosure
regarding personal or
room searches and
protocols for
confiscation of
contraband. The
program must have a
disclosure regarding
personal or room
searches and protocols
for confiscation of
contraband.
Authorizations. 419-470- Yes[ ] No✓ The program now has an authorization that all visitation resources
0160(3)(c). Visitation must be pre-approved. This authorization is reviewed and signed
resources are pre-approved. by the youth's parent or guardian at the intake meeting of a youth
- Although the program is into the program.
documenting approved
visitation resources for
each youth in the

15
program, the program
does not have an
authorization that all
visitation resources
must be pre-approved.
The program must
ensure that they have an
authorization that all
visitation resources
must be pre-approved.
Authorizations. 419-470- Yes[ ] No✓ The program now has an activity specific authorization that
0160(3)(d). Activity specific ensures that all potentially hazardous activities in which children
authorizations are pre- in care may participate in while enrolled in the program are pre-
approved to allow children to approved. This authorization is reviewed and signed by the
participate in potentially youth's parent or guardian at the intake meeting of a youth into
hazardous activities, including the program.
but not limited to using
motorized yard equipment,
swimming, and horseback
riding.
- The program does not
have a pre-approved
authorization to allow
children to participate in
potentially hazardous
activities, including but
not limited to hiking or
using motorized yard
equipment such as
lawnmowers. The
program must have a

15
pre-approved
authorization to allow
children to participate in
potentially hazardous
activities including but
not limited to hiking or
using a motorized lawn
mower.
Information about Children in Yes[ ] No✓ The program's summary sheet now contains the name, gender,
Care. 419-400-0190(1)(a). date of birth, religious preference, and previous address of the
Summary sheet contains the child. This summary sheet is contained in the child file of each
following: (a)The name, child enrolled in the program.
gender, date of birth, religious
preference, and previous
address.
- The program's summary
sheet does not include
an area to list the
previous address for the
child. Also, although the
program's summary
sheet includes an area to
document a child's
religious preference, the
program's staff are not
providing documentation
in the allowed area. The
program's summary
sheet must include an
area to indicate the
child's previous address

15
and the program's staff
must complete all
required fields on the
program's summary
sheet, including the
child's religious
preference, if applicable.
Information about Children in Yes[ ] No✓ The program's summary sheet on each child now includes an area
Care. 419-400-0190(1)(e). to list other professionals to be involved in service planning, if
Summary sheet contains the applicable. The program must also ensure that staff are
following: (e) The name, completing all required fields on the child's summary sheet.
address, and telephone
number of:
(A) The child in care's
parents.
(B) The child in care's legal
guardian, if different than
the parents, and a copy of
the document that provides
for his or her authority over
the child in care.
(C) Other persons
significant to child
(D) Other professionals to
be involved in service
planning (if applicable).
- The program's summary
sheet does not include
an area to list (c) Other
professionals to be
involved in service

15
planning (if applicable).
The program's summary
sheet must include an
area to list other
professionals to be
involved in service
planning (if applicable).
Case Management. 419-470- Yes[ ] No✓ The program's discharge summaries now include all required
0170(3)(c)(A-G). Discharge fields.
summary must include:
(A)Current medications
(B)Name of the physician or
qualified medical professional
who prescribed each
medication
(C)Any outstanding medical or
other appointments
(D)Summary of the child's
participation in the program
and progress achieved
(E)Results of evaluations
(F)Recommendations
regarding services
(G)Discharge destination.
- The program's discharge
summaries do not
include all required
information. The
program's discharge
summaries do not
include (A) Current

15
medications of child; (B)
Name of the physician or
qualified medical
professional who
prescribed each
medication; (C) Any
outstanding medical or
other appointments; and
(E) Results of
evaluations. The
program's discharge
summaries must include
all required information.
Records Relating to Restraint Yes[ ] No✓ The program is now providing notice regarding how to access the
& Involuntary Seclusion. 419- quarterly reports to the parents or guardians of children in care.
400-0180(13)(e). Each child This notice is being provided at the time of a child in care's intake
caring agency shall provide meeting into the program and is also being provided on the
notice regarding how to children in care's Initial and On-Going Treatment Plans.
access the quarterly reports to
the parents or guardians of
children in care in the
program. The child caring
agency shall provide the
notice upon the child in care's
admission and at least two
times each year thereafter.
- The program is not
providing notice
regarding how to access
the quarterly restraint
reports to the parents or

15
guardians of children in
the program. The
program must ensure
they are providing notice
regarding how to access
the quarterly restraint
report to the parents or
guardians of children in
the program. The
program shall provide
the notice upon the
child.
Financial Records. 419-470- Yes[ ] No✓ The program is now maintaining an updated financial record for
0170(4). Financial records each child in care in the program. The program's financial record
contain date, amount, source, form also includes all required fields.

interview_summary:
During the unannounced site review, a good deal of discussion took place with Poe Foster, Program Manager and with Asia
Van Horn, supervisor of the Klahre House Residential Program. Shortly after the site visit, I was also able to have a
telephone conversation with Melanie Kelly, Program Director. In addition, two youth enrolled in the Klahre House
Residential Program and one staff of the program were randomly selected and individually interviewed. The staff person
was interviewed via the telephone.
One of the youth enrolled in the residential program stated the program was "nice," that the program was a "homelike
setting," that the food was "pretty good,' and that they went on lots of outings in the community. The other youth stated he
"liked living in the program," that he had his own room, that the food was OK, and that he was learning a great deal in the
program, especially in his gardening and culinary classes. He also stated he liked the program more than other programs he
had previously been enrolled since he had his own room. Both youth stated that staff were helpful and nice. When asked if
they would change anything about the program, one of the youth could not think of anything they would change and the
other wished the program would provide him with "more free time" and he wished the program would allow him to call and
talk with old friends. This youth also stated he wished his Probation Officer didn't take so long to approve visits with his
family members outside of the program. Both youth also stated they felt safe in the program both during the day and at
night while in their bedrooms, and both youth reported they were able to make private calls when they wanted to persons on
their approved contact list. Both youth also denied ever being treated badly or observing anotheryouth in the program being
treated badly in any way by program staff.
During telephonic interview with the one line staff, we discussed his duties as a Youth Care Specialist. He stated he enjoys
working for the agency and feels supported in his role. He also stated he always has someone to call, if he were to have a
question and stated the culture of the program is welcoming to everyone, is positive, and is supportive. He also stated he
receives enough information about each child to effectively address their treatment issues and keep them safe and was able
to talk about systems the program had in place to effectively keep staff updated about youth's behaviors and critical
information about new admits into the program. He also stated he felt he received sufficient training and was able to
effectively relay the program's suicide prevention and search policies and stated he had his annual suicide prevention
training coming up in the next week. Finally, he stated his supervisor had discussions with him about suicide prevention,
medication administration, and search, as appropriate and when issues came up.

15

previous_findings:
Repeat Comments
License Renewal Site Visit Findings
11/01/23 Further
Action
Needed
Physical Plant. 419-470- Yes[ ] No✓ During walkthrough of the program, the program was found to be
0020(2)(a) &(c). Buildings are very clean and in good repair. Youth enrolled in the program
smoke free, clean and in good assist in cleaning the program on a twice a week basis.
repair.
- Although the program
was found to be in good
repair, well-kept and

clean, there was some
mold in one of the
youth's showers where
the youth's shampoo
was kept. The program
must ensure there is not
any mold in the youth's
showers.
Residential Care Safety Yes[ ] No✓ The program's monthly fire drill log was observed, and the log
419-470-0080(5)(a). An contained all required fields. In addition, the program was found
evacuation drill occurs to be having monthly fire drills and the fire drill log was being fully
monthly under varying completed.
conditions, is retained 2 years
and contains:
(A) identify of person
conducting drill
(B) date & time
(C) notification method
(D) staff participating
(E) # of children & staff
evacuated
(F) special conditions
simulated
(G) problems encountered
(H) time to complete
- Since the program
opened, the program has
not been having monthly
evacuation drills as, to
date, the program has
documented only 2 drills,

15
in September and
October 2023. In
addition, the program's
fire drill log does not
contain all required
fields AND staff are
sometimes not
completing the required
fields on the form.
These fields include: (A)
Identity of person
conducting drill; (D) Staff
participating; and (C)
Problems encountered.
The program must
ensure that monthly
evacuation drills are
occurring, that their
evacuation drill log
contains all required
fields, and that the
evacuation drill log is
being fully completed by
staff.
Medication 419-470-0100(7)(c). Yes No✓ The program's medications are kept in a locked metal storage
Medications are inaccessible cabinet in one of the main living areas of the house. In addition,
to children and stored behind the medications are now also kept in a locked storage compartment
at least two locking within the locked metal storage cabinet; thus, they are now stored
mechanisms. This does not behind two locking mechanisms.
apply to Naloxone.

15
- The children's
medications are
currently kept in a locked
metal storage cabinet
and the metal storage
cabinet is in one of the
main living areas of the
house. The program
must ensure that
medications are stored
behind at least two
locking mechanisms.
Medication. 419-470-0100(10). Yes[ ] No✓ During the unannounced site review, a child's MAR was randomly
Written record of the selected and observed. All required fields of the child's MAR were
administration of medication completed including a description of the medication and the
includes: possible adverse reactions to the medication, as noted on the
(a) name prescription bottle, that the child may experience.
(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.
- The program's MAR
contains all required
fields. However, all
required fields are not
being completed. These

15
fields include: (b)
description of the
medication; and (h)
possible adverse
reactions. The program
must ensure that staff
are fully completing each
child's MAR.
Consents. 419-470-0160(1)(e). Yes[ ] No✓ The program now has a consent stating that the program will allow
Allow access as defined in access as defined in 419-400-0230 and 0240. This consent is
419-400-0230 & 0240. reviewed and signed by the youth's parent or guardian at the
- The program does not youth's intake meeting into the program.
have a consent stating
that the program will
allow access as defined
in 419-400-0230 and
0240. The program must .
have a consent stating
that the program will
allow access as defined
in 419-400-0230 and
0240.
Consents. 419-470-0160(1)(g). Yes[ ] No✓ The program now has a consent that the program will apply the
Apply the reasonable and reasonable and prudent parent standard. This consent is reviewed
prudent parent standard. and signed by the youth's parent or guardian at the intake meeting
- The program does not of a youth into the program.
have a consent that it
will apply the reasonable
and prudent parent
standard. The program
must have a consent that

15
it will apply the
reasonable and prudent
parent standard.
Disclosures. 419-470- Yes[ ] No✓ The program now has a disclosure regarding personal and room
0160(2)(a). searches and protocols for confiscation of contraband. This
Parent/guardian has disclosure is reviewed and signed by the youth's parent or
acknowledged in writing: guardian at the intake meeting of a youth into the program.
Information regarding
personal or room searches
and protocols for confiscation
of contraband.
- The program does not
have a disclosure
regarding personal or
room searches and
protocols for
confiscation of
contraband. The
program must have a
disclosure regarding
personal or room
searches and protocols
for confiscation of
contraband.
Authorizations. 419-470- Yes[ ] No✓ The program now has an authorization that all visitation resources
0160(3)(c). Visitation must be pre-approved. This authorization is reviewed and signed
resources are pre-approved. by the youth's parent or guardian at the intake meeting of a youth
- Although the program is into the program.
documenting approved
visitation resources for
each youth in the

15
program, the program
does not have an
authorization that all
visitation resources
must be pre-approved.
The program must
ensure that they have an
authorization that all
visitation resources
must be pre-approved.
Authorizations. 419-470- Yes[ ] No✓ The program now has an activity specific authorization that
0160(3)(d). Activity specific ensures that all potentially hazardous activities in which children
authorizations are pre- in care may participate in while enrolled in the program are pre-
approved to allow children to approved. This authorization is reviewed and signed by the
participate in potentially youth's parent or guardian at the intake meeting of a youth into
hazardous activities, including the program.
but not limited to using
motorized yard equipment,
swimming, and horseback
riding.
- The program does not
have a pre-approved
authorization to allow
children to participate in
potentially hazardous
activities, including but
not limited to hiking or
using motorized yard
equipment such as
lawnmowers. The
program must have a

15
pre-approved
authorization to allow
children to participate in
potentially hazardous
activities including but
not limited to hiking or
using a motorized lawn
mower.
Information about Children in Yes[ ] No✓ The program's summary sheet now contains the name, gender,
Care. 419-400-0190(1)(a). date of birth, religious preference, and previous address of the
Summary sheet contains the child. This summary sheet is contained in the child file of each
following: (a)The name, child enrolled in the program.
gender, date of birth, religious
preference, and previous
address.
- The program's summary
sheet does not include
an area to list the
previous address for the
child. Also, although the
program's summary
sheet includes an area to
document a child's
religious preference, the
program's staff are not
providing documentation
in the allowed area. The
program's summary
sheet must include an
area to indicate the
child's previous address

15
and the program's staff
must complete all
required fields on the
program's summary
sheet, including the
child's religious
preference, if applicable.
Information about Children in Yes[ ] No✓ The program's summary sheet on each child now includes an area
Care. 419-400-0190(1)(e). to list other professionals to be involved in service planning, if
Summary sheet contains the applicable. The program must also ensure that staff are
following: (e) The name, completing all required fields on the child's summary sheet.
address, and telephone
number of:
(A) The child in care's
parents.
(B) The child in care's legal
guardian, if different than
the parents, and a copy of
the document that provides
for his or her authority over
the child in care.
(C) Other persons
significant to child
(D) Other professionals to
be involved in service
planning (if applicable).
- The program's summary
sheet does not include
an area to list (c) Other
professionals to be
involved in service

15
planning (if applicable).
The program's summary
sheet must include an
area to list other
professionals to be
involved in service
planning (if applicable).
Case Management. 419-470- Yes[ ] No✓ The program's discharge summaries now include all required
0170(3)(c)(A-G). Discharge fields.
summary must include:
(A)Current medications
(B)Name of the physician or
qualified medical professional
who prescribed each
medication
(C)Any outstanding medical or
other appointments
(D)Summary of the child's
participation in the program
and progress achieved
(E)Results of evaluations
(F)Recommendations
regarding services
(G)Discharge destination.
- The program's discharge
summaries do not
include all required
information. The
program's discharge
summaries do not
include (A) Current

15
medications of child; (B)
Name of the physician or
qualified medical
professional who
prescribed each
medication; (C) Any
outstanding medical or
other appointments; and
(E) Results of
evaluations. The
program's discharge
summaries must include
all required information.
Records Relating to Restraint Yes[ ] No✓ The program is now providing notice regarding how to access the
& Involuntary Seclusion. 419- quarterly reports to the parents or guardians of children in care.
400-0180(13)(e). Each child This notice is being provided at the time of a child in care's intake
caring agency shall provide meeting into the program and is also being provided on the
notice regarding how to children in care's Initial and On-Going Treatment Plans.
access the quarterly reports to
the parents or guardians of
children in care in the
program. The child caring
agency shall provide the
notice upon the child in care's
admission and at least two
times each year thereafter.
- The program is not
providing notice
regarding how to access
the quarterly restraint
reports to the parents or

15
guardians of children in
the program. The
program must ensure
they are providing notice
regarding how to access
the quarterly restraint
report to the parents or
guardians of children in
the program. The
program shall provide
the notice upon the
child.
Financial Records. 419-470- Yes[ ] No✓ The program is now maintaining an updated financial record for
0170(4). Financial records each child in care in the program. The program's financial record
contain date, amount, source, form also includes all required fields.
purpose, signatures.
- The program is not
maintaining an updated
financial record for each
youth in the program.
The program's financial
record form also does
not include all required
fields, or the financial
record form is not being
fully completed. The
program must ensure
that each youth in the
program has an updated
financial record and that
the program's financial

15
record form contains all
required fields and that
all required fields are
being fully completed by
program staff.
Personal Possessions Yes[ ] No✓ The program is now maintaining an individual written inventory
Records. 419-470-0170 (5). for each child in care of all personal possessions and this inventory
Individual written inventory of is being updated, as needed.
all personal possessions is
maintained and updated as
needed.
- The program is not
maintaining an updated
written inventory of each
child's personal
possessions. The
program must ensure
they are maintaining an
updated personal
possessions inventory
for each child in the
program.
New Findings from Site Visit Comments
There were not any new findings
from the site visit.

15

excerpt:
419-470-0170 (5). for each child in care of all personal possessions and this inventory
Individual written inventory of is being updated, as needed.
all personal possessions is
maintained and updated as
needed.
- The program is not
maintaining an updated
written inventory of each
child's personal
possessions. The
program must ensure
they are maintaining an
updated personal
possessions inventory
for each child in the
program.
New Findings from Site Visit Comments
There were not any new findings
from the site visit.
15
There were not any new findings
from the site visit.
15