summary: Unannounced - 3 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Trillium Family Services – Parry Center
Executive Director: Kim Scott, CEO
Program Director(s): Amy McAdams
Date of Unannounced: December 20, 2022
Licensing Coordinator: Aubrey Kelly
Other Regulatory or Accrediting Agencies: OHA, Joint Commission
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
2021 Unannounced Site Visit 12-09-2021 – Findings
Parry Center Further Action
Needed
413-215-0576(2) Parent/guardian has Yes☐ No Three client files reviewed contained the required disclosure.
acknowledged in writing: (c) Any policies
and procedures upon request:
PCC – 2 of 5 files were missing
documentation of all disclosures
Files reviewed did not contain the consent.
The program shall ensure all required
consents are signed by the legal guardian.
413-215-0576(3) (b) Child specific visitors: Yes☐ No Three client files reviewed contained the required authorization.
PCC – 2 of 5 files were missing
documentation of activity specific
authorizations
1
(rev. 07/21/2022)
Files reviewed did not contain the consent.
The program shall ensure all required
consents are signed by the legal guardian.
413-215-0576(3) (c) Visitation resources Yes☐ No Three client files reviewed contained the required authorization.
are pre-approved:
PCC – 2 of 5 files were missing
documentation of activity specific
authorizations
Files reviewed did not contain the consent.
The program shall ensure all required
consents are signed by the legal guardian.
New Findings from Site Visit Comments
None
Interview Summary
Client #1: They have been here for 2 months. They have previously been at Unity and Randall’s. They like it here, there are ups and
downs. Groups are fun, they like the art and active groups. They don’t like when peers are fighting and arguing. Their favorite staff
is Clara, she listens. They feel safe here and gets phone calls and visits with family. The food is better than they expected, they get
enough to eat. They have not been in any restraints since being at the program. Staff keeps them safe when other peers are
freaking out. They like school, the program allows lots of breaks during school. They would not change anything about the program.
Client #2: They have been here for 1 week. They previously were at Albertina Kerr and really liked it there. They have phone calls
and visits with family. They like the staff here, they are very nice. Their favorite staff is Rich. They don’t like one staff because they
are sarcastic. The food is food, they get enough to eat. They feel safe here.
2
Observations
The program was clean and home-like. Staff de-escalated clients effectively during the site visit.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Trillium – Parry Center 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 Aubrey.J.Kelly@dhsoha.state.or.us.
Licensing Coordinator’s Signature: ________________________ Date: _1_2_-_2_8_-2__0_2_2_ ________
Manager Review: ______________________________________ Date: _1_2_-_2_8_-_2_0_2_2_ _______
3

licensee: Trillium Family Services - Parry Center

visit_date: December 20, 2022

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
2021 Unannounced Site Visit 12-09-2021 - Findings
Parry Center Further Action
Needed
413-215-0576(2) Parent/guardian has Yes[ ] No Three client files reviewed contained the required disclosure.
acknowledged in writing: (c) Any policies
and procedures upon request:
PCC - 2 of 5 files were missing
documentation of all disclosures
Files reviewed did not contain the consent.
The program shall ensure all required
consents are signed by the legal guardian.
413-215-0576(3) (b) Child specific visitors: Yes[ ] No Three client files reviewed contained the required authorization.
PCC - 2 of 5 files were missing
documentation of activity specific
authorizations
1

Files reviewed did not contain the consent.
The program shall ensure all required
consents are signed by the legal guardian.
413-215-0576(3) (c) Visitation resources Yes[ ] No Three client files reviewed contained the required authorization.
are pre-approved:
PCC - 2 of 5 files were missing
documentation of activity specific
authorizations
Files reviewed did not contain the consent.
The program shall ensure all required
consents are signed by the legal guardian.
New Findings from Site Visit Comments
None
Interview Summary
Client #1: They have been here for 2 months. They have previously been at Unity and Randall's. They like it here, there are ups and
downs. Groups are fun, they like the art and active groups. They don't like when peers are fighting and arguing. Their favorite staff
is Clara, she listens. They feel safe here and gets phone calls and visits with family. The food is better than they expected, they get
enough to eat. They have not been in any restraints since being at the program. Staff keeps them safe when other peers are
freaking out. They like school, the program allows lots of breaks during school. They would not change anything about the program.
Client #2: They have been here for 1 week. They previously were at Albertina Kerr and really liked it there. They have phone calls
and visits with family. They like the staff here, they are very nice. Their favorite staff is Rich. They don't like one staff because they
are sarcastic. The food is food, they get enough to eat. They feel safe here.
2
Observations
The program was clean and home-like. Staff de-escalated clients effectively during the site visit.

excerpt:
413-215-0576(3) (c) Visitation resources Yes[ ] No Three client files reviewed contained the required authorization.
are pre-approved:
PCC - 2 of 5 files were missing
documentation of activity specific
authorizations
Files reviewed did not contain the consent.
The program shall ensure all required
consents are signed by the legal guardian.
New Findings from Site Visit Comments
None
None


state: OR

facility_name: Parry Center

summary: License Renewals - 16 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care
Licensee: Trillium Family Services Date of site visit: July 25th-26th, 2023 and August 29th-31st, 2023
Executive Director: Jamie Vandergon Licensing Coordinator: Aubrey Kelly
Board Chairperson: Eric Hunter
Other Regulatory or Accrediting Agencies: Oregon Health Authority
Program Compliance: The program was found to be compliant or will be compliant with OAR 419-400-0005 to 419-400-0310, Licensing Umbrella
Rules, and OAR 419-470-0010 to 419-470-0180, 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): Parry Center and Children’s Farm Home serve children between the ages of 5 and 17 who are struggling with mental
health challenges and are in need of 24-hour residential treatment. The programs provide secure and nurturing healing environments within locked
facilities. Clients have access to fenced and open recreations areas, therapeutic activities aimed at increasing social and emotional well-being,
opportunities for home visits and community outings if appropriate.
Edwards Day Treatment is a day treatment program located in the Portland area. Teachers are from the Portland Public School District.
North Point Day Treatment is located on the Children’s Farm Home Campus and is a collaborative program that specializes in individual, family, and
group therapy; group skills training, psychiatric oversight; treatment planning; care coordination; and educational services to students 5-18 who
experience emotional or behavioral difficulties impacting their ability to be successful in school and home environments
Sender House young adult independent living group home is a voluntary community based residential home. It serves youth with significant mental
health concerns that are being transitioned out of or being diverted from a hospital, residential, corrections, or foster care system. The program is
designed to help young people transition into adulthood by meeting their developmental, psychosocial, and physical needs as emerging adults with
significant mental health needs.
Program type and services:
Parry Center and Children’s Farm Home– Psychiatric Residential Treatment Services (PRTS), sub-acute and secure inpatient.
Edwards Day Treatment and Northpoint Day Treatment –Psychiatric Day Treatment.
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Form Rev. 04/18/2023
Sender House – Transitional Age Youth Program: Residential Treatment Home.
Capacity and Age Range:
Parry Center – 36 capacity, age range 5-18.
Edwards Day Treatment – 48 capacity, age range 5-18.
Children’s Farm Home – 48 capacity, age range 11-18.
Northpoint Day Treatment – 24 capacity, age range 5-18.
Sender House – 4 capacity, age range 17-24.
Funding sources: Oregon Health Plan (OHP) via Coordinated Care Organizations (CCOs)Private insurance: Moda, Kaiser, Regence, Providence,
CIGNA, First Choice, Pacific Source, Samaritan Health insurance companies.
Contracts and sources for referrals: CareOregon (Columbia Pacific CCO, Jackson Care Connect), CareOregon (Health Share of Oregon),
Cascade Health Alliance, Greater Oregon Behavioral Health Inc. (GOBHI) CCO, InterCommunity Health Network CCO, Options for Southern
Oregon (AllCare Josephine, Jackson and Douglas counties), Pacific Source Community Solutions, SW Oregon IPA (Advanced Health CCO),
Trillium Community Health Plan, Umpqua Health Alliance, Yamhill County Care Organization.
Average length of stay: Residential – 85 days. Day treatment – 35 days.
Average daily population served: Parry Center and Edwards Day Treatment – 48. Children’s Farm Home and Northpoint Day Treatment – 51.
Number of children served annually: 480 clients
Use of seclusion or restraint: Yes - CPI
Interviews, Observations:
Parry Center client: They have been at the program since 06.27.2023. Their favorite staff is everyone on the front end shift of the week and some
on the back end shift of the week. They feel comfortable talking with staff. The food is ok, they like the cheesy rice and bar-be-que are their favorite.
They get along with the other clients. There are a lot of groups every day. They haven’t been in a hold since being at the program. They see their
therapist every week. They have family calls and visits. The program does community outings. They really like art and wouldn’t change anything
about the program.
Edwards Day Treatment client: They have been at the program for a month. They have been a lot of different schools, they really like it here. They
see their therapist one time a week. The food is good, the burrito bowls are their favorite. They get along with the other clients. There are a lot of
staff they can talk to. Their favorite staff is Phillip. They have activities on Wednesdays. No one has put their hands on them since being at the
program.
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Form Rev. 04/18/2023
Edwards Day Treatment staff: They are a skills trainer and have been since November 2022. They attended 1 full week of academy training which
included 2 full days of Crisis Prevention Institute (CPI) training. Training included in how to lead a group, documentation, how to talk to clients,
privacy training and mandatory reporting training. Their supervisor check ins with them every day. They lead treatment groups which include art
groups, yoga and a lot of physical activities. Staff meet every week with the therapists to staff the clients. Clients are never left unattended, there are
four kids in their classroom. Communication is good, they know all the other staff. Staff support one another. It can be hard when staff are out,
additional responsibilities tend to fall on the skills trainer.
Sender House client: They have been at the program for over a month, they were previously at Children’s Farm Home, Albertina Kerr Centers and
Unity. They are going to be starting college soon. The staff are nice and respectful. The clients make their own meals. They feel safe here.
Northpoint client: They have been the program for one month. They see their therapist two times a week. The food is good, but they would change
the cheese if they could. Staff are always available to check in with. They really like school at the program and how they can complete credits. They
have family therapy one time a week. They like clients are allowed to have snacks and take naps. Staff are really cool. They feel safe here.
Children’s Farm Home client: They have been at the program for almost two months. They like they can go outside anytime here. They have been
on outings and really enjoys those. They have visits and phone calls with their family and have family therapy one time a week. They are working on
their goals and feel safe here. They have been in one hold at the program. They like the food and enjoy the chicken strips and pizza the most. Their
favorite staff is Mark. Mark is friendly and open. If they could change something at the program it would be to have animals in the milieu.
Children’s Farm home client: They have been at the program for two months. The staff really shine. The food is ok, there is a lot of variety. They
have visits and phone calls with their family. They don’t feel like they have made progress here. They wish they had longer therapy sessions. They
feel safe here.
Children’s Farm home staff: 6 Children’s Farm Home staff were interviewed. The following is a summary of the interviews. Staff consistently
reported more staff are needed on campus. Staff reported when they call for additional staff support during an incident, not enough staff respond, or
no staff respond at all. Staff reported feeling like they are keeping clients engaged in treatment and keeping them on track. Staff reported some are
not able to take their breaks due to not having enough staff to cover. Staff reported communication from leadership has improved. Leadership has
been doing meetings twice a week with staff, and staff reported the meetings are helpful as leadership can hear their concerns.
Program Strengths (as identified by Trillium):
Children’s Farm Home:
Cummings: In general, the physical plant is a strength. The primary building, which has the main milieu, bedrooms, two breakout
spaces, kitchen, nursing station and some offices, is locked. There is a fenced yard, and our other space includes two breakout rooms,
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Form Rev. 04/18/2023
two bathrooms and two more offices, but these are not locked from the inside and provide easy access to the yard. This unit is a
blended PRTS, Sub Acute and Secure Adolescent Inpatient (SAIP) unit. The opportunity to have a blended group is also a strength, as
this can provide hope, as some youth will be actively working toward discharge at any given time. The Skills Trainer Supervisor group
have several years of experience as both direct care staff and many as managers in prior fields. The clinical team has a primary
psychiatrist that sees all our youth.
Mallet: The unit has a strong, dynamic team. The unit has a collaborative environment and good communication standards.
Powers: The unit focuses on skill building interventions with a non-punitive approach. The unit focuses on learning from our actions and
behaviors. The unit creates a community for the clients that supports them and provides a caring safe environment. The unit focuses on
staff retention and supporting our staff.
Redwood: The unit is resilient and good at adjusting to changing acuity and milieus. The staff are talented at working with diverse client
population. Staff also do well communicating with the supervisory team of the program regarding concerns so that they can be
addressed. The unit has been working on improving staff compliance with sticking to scheduled programming and problem-solving
documentation concerns that have come up, and there has been improvement in these areas.
Sequoia: The unit has a strong connection/frequent communication between floor staff and all levels of leadership. The turnover rate
has been much lower and with staff staying with the unit on average well over 6 months. Client engagement in activities has led to a
reduction in incidents. Staff are passionate about the work and bought into the program.
Parry Center:
West 1: The West 1 unit strengths are trauma informed, individualized, and DBT inspired (evidence-based programming). Additionally,
West 1 is a program that values learning. In the last year, West 1 has had 2 graduate level therapist interns from Lewis and Clark
working on our clinical team. This experience provides both learning opportunities for external graduate students but also allows current
clinicians to support newer clinicians in learning and working together. West 1 focuses on adolescents ages 14-17 and has some
creative and supportive programming including “Adulting” (a group that builds life skills such as budgeting), DBT skills groups (skills
trainer led groups 4x per week increasing mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness skills),
“Polaroos” (a group where clients are given the opportunity to engage in therapeutic activities/social groups with the youngest clients on
campus).
West 2: Strong staffing and teamwork has been a strength. Staff do a great job of meeting youth where they are at and working
collaboratively to create individualized care for each youth and family.
North 1: North 1 has a strong identification with secure inpatient and serving very traumatized youth, with a compassionate and trauma
informed approach. North 1 has had strong leadership, although the unit is experiencing the turnover of our Clinical Program Manager.
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Form Rev. 04/18/2023
Edwards Day Treatment:
The program has a strong, dynamic team. The program serves a large amount of youth at the PHP level of care within Trillium. The
program individualizes every client’s treatment and is able to think creatively in terms of interventions.
North Point Day Treatment:
Strong clinical supports and staffing have been a strength in the program. Continued strong partnership with Linn-Benton-Lincoln
Education Service District is also a continued strength for the North Point Program.
Sender House:
With leadership change, there has been an increase in clinical interventions and accountability for youth in the program. The program
has been more engaged and clinically focused with the leadership change and finding ways to engage clients in more creative ways while
allowing staff to share their interests within the program as well.
Program Challenges (as identified by Trillium):
Children’s Farm Home:
Cummings: The ability for athletic youth to gain access to the roof. The turnover in Skills Trainers and constantly having new team
members.
Mallet: Overall the leadership/Clinical team is new and still learning how to work as a fully cohesive team. The age of the physical building also
poses unique and ongoing challenges.
Powers: The unit has experienced struggles with staffing retention and burn out. The unit has been using retreats, but limited resources still make
this difficult. The program at times struggles with the physical limitations of the building in the way staff are not able to separate clients when
needed.
Redwood: A challenge has been conducting follow-up in a manner that is efficient as the program has had a high level of traveling workers or
covering staff members which requires the supervisor team to coordinate the follow-up with other supervisors. Follow-up has improved in efficiency
with more core staff members working in the program. A challenge that has also come up in the past year was unit acuity which required
significantly more staff members to be present in the program due to multiple clients on significantly increased supervision status. Acuity has
decreased with the change to a blended unit which has allowed for more intentional admissions and milieu management.
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Form Rev. 04/18/2023
Sequoia: Staff are concerned with the number of staff on each shift. Restrictions on items allowed for creative engagement due to being a SAIP
unit.
Parry Center:
North 1: North 1 is still recovering from turnover, that occurred at the outset of the pandemic. This has led to significant loss of knowledge in the
context of the milieu, including crisis management and leading groups. In the past 60-days, the unit has made significant strides in improving
programing, so that there are more active and engaging activities, and strengthening of the management of crisis. The unit continues to have
significant staffing issues as the unit works to rebuild and develop new leaders at the milieu level. This will likely continue over the next year, as it
will take time to identify and develop effective supervisors, while the unit also continues to improve structure/consistency within the milieu.
North 2 The unit’s largest challenges are also related to the frequent experience of aggressive incidents, as the client population is younger children
who are primarily referred due to aggressive behaviors. Maintaining all of the necessary protocols and procedures while also providing quality care
and attuned individualized interventions in highly tumultuous, emotionally charged situations can be very difficult. It is also challenging to train new
staff to all of those protocols and procedures while also maintaining a heavy focus on training them to remain calm and rational in their decision
making. The unit has also had some challenges with individual cases recently who have had multi-system involvement and difficulties identifying
placements, services, and discharge plans for them, leading to longer lengths of stay.
West 1: West 1 has struggled with staffing. There are many factors that influence this challenge including changes to the workforce that occurred
during the Covid-19 pandemic as well as an increase in sick calls across campus. West 1 also has struggled with after-care planning due to very
limited services in the community, long wait-lists, and few options in rural areas of Oregon. Planning for a client to step back into the community with
adequate mental health support has been increasingly challenging.
West 2: West 2 has had quite a bit of turnover in the clinical leadership positions within the past year. This has led to a large learning curve for new
clinicians coming onto the team.
Edwards Day Treatment:
The conditions of the building and the constant need for maintenance work creates challenges.
North Point Day Treatment:
Coming out of the pandemic, illness of youth and needs for quarantine continue to show disruptions in attendance. The program has seen some
psychiatric changes in the program within the last year which create shifts in the clinical practice. Acuity of clients has been higher in program, for
this level of care.
Sender House:
The program has seen acuity in severity of presentation to be significantly higher than previous years. This has created challenges in finding youth
who are appropriate for the program, and successful with this level of intervention in the community.
Changes that have occurred in the last 2 years:
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Form Rev. 04/18/2023
The most significant changes have been adapting to COVID and the lingering impact. Prior to COVID, Parry Center and Edwards served approximately
67 clients on any given day (as opposed to the 48 listed above) and Children’s Farm Home and Northpoint served approximately 68 clients on any
given day (as opposed to the 51 cited above). The reduction is largely due to staffing challenges. The teams are slowly building back to pre-covid
staffing.
Other changes are a re-distribution of levels of care. At Parry Center, they are limiting the number of Secure Inpatient (SIP) youth to 12, where it was
frequently at 15-16 in the past few years. This has caused a corresponding increase in the number of PRTS youth served. At Children’s Farm Home,
they are limiting the number of SIP youth to 20, where it was frequently at 28 in prior years. As with Parry Center, this has caused a corresponding
increase in the number of PRTS youth served.
Additionally, in one program on each campus, we have incorporated PRTS and Subacute services into a program that was previously exclusively
SIP. Edwards Day Treatement has had a good number of staff turn over as well as the child psychiatrist turn over within the last 6-months. The
program had to adjust to the ‘new normal’ as COVID has started to become less of an issue.
At Children’s Farm Home, the Redwood unit was moved to a blended unit with both SAIP and PRTS clients. The Powers unit was shut down and
re-opened in February 2022. The Sequoia unit has moved away from traditional psychoeducation groups and put more focus on activities that are
passionate to engage clients in skill practice within those activities. The Cummings unit has gone from a low census of 6 clients to 12 clients.
At Parry Center, the COVID-19 pandemic changed many aspects of residential treatment. Finding in person after-care services, particularly at the
intensive outpatient level of care, has been increasingly challenging. Additionally, changes have continued from the impact of the Senate Bill.
Documentation requirements take up a much greater amount of time both in training and auditing. There have been some leadership changes.
There has been a significant amount of turnover within the past two years.
Lawsuits: None
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report Trillium Family Services 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 Aubrey Kelly at Aubrey.J.Kelly@odhsoha.oregon.gov.
Recommendations:
None
Exceptions:
Window exception - approved
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Form Rev. 04/18/2023
Changes in License:
None
Summary of Review
Program and Services
Yes No N/A Corrective Actions/Comments
419-400-0020 (2)
Program and services are in scope of license X
Governance of the Agency
Yes No N/A Corrective Actions/Comments
419-400-0040
(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
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
Yes No N/A Corrective Actions/Comments
419-400-0040
(3)(a) knowledge of requirements for
providing care and treatment appropriate to X
programs
(3)(g) Approval from BCU X
Discipline, Behavior Management, and
Suicide Prevention Yes No N/A Corrective Actions/Comments
419-400-0150
(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
Contractors (if applicable) Yes No N/A Corrective Actions/Comments
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Form Rev. 04/18/2023
419-400-0120(6)
(a) Agency ensures the contractor meets the
requirements of this rule and Chapter 413 X
division 215
(b)(B) Contract includes the following:
(i) Services provided
(ii) Contractor fees
(iii) Disclosure of information from contractor
to agency
(iv) Lines of authority X
(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
Restraints and Involuntary Seclusion
Yes No N/A Corrective Actions/Comments
419-400-0180
(11)(d) Each child caring agency that
submits a report under this section shall
make its quarterly report available to the
X
public upon request at the Child Caring
Agency’s main office and on the child caring
agency’s website if applicable.
Supplemental Information Provided by
Yes No N/A Corrective Actions/Comments
CCA
Documents as indicated on the form titled
X
“Renewal Licensing Required Documents”
Documents as indicated on form titled The program has not submitted their tax compliance certificate. The program is actively
“Required Financial Documents and X working to obtain the certificate. The program shall ensure their tax compliance certificate
Information” is obtained and submitted to Licensing.
All required policies and procedures as
X
identified in the “Umbrella Rules”
All required policies and procedures as
X
identified in “Agency Type Specific Rules”
Parry Center, Children’s Farm
Home and Sender House
Physical Plant
Yes No N/A Corrective Actions/Comments
419-400-0090(3)(a) Foster Rights Posted (if
X
children in DHS custody)
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Form Rev. 04/18/2023
419-400-0100(1) Sufficient safe space,
X
equipment, and office equipment
419-400-0230(12) License is posted in
X
common area at each facility
419-470-0020(2)(a) &(c) Buildings are Parry Center
smoke free, clean and in good repair North 1: One client’s bedroom was messy and had water on the floor. Room A5 and the
sensory room were messy and had client belongings all over the floor. The program shall
ensure all buildings are clean.
X
Children’s Farm Home
Sequoia: Bedrooms number 2 and 9 were messy and had belongings all over the floor.
Cummings: Bedroom number 5 was messy and had belongings all over the floor. One
bathroom had the word “fuck” carved in the wall.
The program shall ensure all buildings are clean and in good repair.
419-470-0020 (2)(d) Rooms are free of
X
harmful drafts, odors, and excessive noise
419-470-0020 (2)(e) Rooms are adequate in
X
size and arrangement
419-470-0020 (2)(f) System provides a
continuous supply of hot and cold water to X
taps located throughout the facility
419-470-0020 (2)(h) Building is well
ventilated and room temperature is within a X
normal comfort range
419-470-0030 (1) All parts of the facility
X
ensure the safety of children
Room and Space Requirements
Yes No N/A Corrective Actions/Comments
419-470-0030
(2) There is a separate living room or lounge X
area – 15 SF minimum per child
(5) There is a separate dining room with X
capacity for ½ of children in care and 15 SF
per child in care
(7) Laundry is separate from living, kitchen, X
and dining areas
(8) Separate storage areas are provided for X
food, kitchen supplies, utensils, clean linens,
soiled linens and clothing, cleaning supplies
and equip, poisons, chemicals, outdoor
recreational and maintenance equipment.
(Hazardous materials are properly labeled, in
original container and locked)
(9) Outdoor activity area is protected from X
vehicles and other hazards and of a size and
availability appropriate to the age and needs
of children in care
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Form Rev. 04/18/2023
(11) Time-out rooms: Rooms used for time X
out or quiet time must have adequate space,
heat, light and ventilation and must not be
capable of locking.
Room and Space Requirements
Bedrooms Yes No N/A Corrective Actions/Comments
419-470-0030(3)
(a) Adequate furnishings and personal items X
(b) Separate from rooms used for dining,
X
living, laundry, kitchen, and storage
(c) Meet Oregon Fire Code Requirements X
(d) Be an outside room, with a window that
operates as designed. If the window is
modified from its original design, the fire
X
marshal must approve the modification and
indicate this room still meets applicable
Oregon Fire Code.
(d) Ceiling at least 90 inches X
(e) Minimum 60 SF per occupant X
(f) No more than 25 if dorm style X
(g) Permanently wired fixtures X
(h) Window covering X
Room and Space Requirements
Bathrooms Yes No N/A Corrective Actions/Comments
419-470-0030(4)
(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 be in good condition
and free of mold
Room and Space Requirements
Kitchen Yes No N/A Corrective Actions/Comments
419-470-0030(6)
(a) Used exclusively for storage, food
preparation, dishwashing, and activities
X
related to eating and food preparation
activities
(b) Walls, floors are easily cleanable X
P a g e 11 | 28
Form Rev. 04/18/2023
(c) Equipment and utensils are easily
X
cleanable, durable, nontoxic, and kept clean
(e) Equipment is easy to clean beneath,
X
between and behind
Furnishings and Personal Items
Yes No N/A Corrective Actions/Comments
419-470-0040
(1) There is a bed with frame, X
(1)(b) clean mattress in good condition,
X
with a minimum thickness of five inches
(1)(c) a pillow in good condition X
(1)(d) a private dresser, closet, or similar
storage area for personal belongings that X
is readily accessible
(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
Yes No N/A Corrective Actions/Comments
419-470-0070
(1)(a) Meals are arranged daily, consistent
with normal mealtimes that occur during the
X
hours of operation and provide snacks
between mealtimes
(1)(b) Menus are prepared in advance in
accordance with USDA guidelines, provide a
X
variety of foods and are adjusted for
seasonal changes including snacks
(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.
Residential Care Safety
Yes No N/A Corrective Actions/Comments
419-470-0080
(2) Written emergency plan that includes X
P a g e 12 | 28
Form Rev. 04/18/2023
(a) Identifying the types of emergencies most
likely to happen where the residential care X
agency is located
(b) Identifying a place to meet for each type
X
of emergency identified
(c) Identifying an alternate shelter if
X
necessary
(d) Ensuring access to necessary
X
medications or medical equipment
(e) How to help each child in care recover
X
after a disaster
(3) Telephone numbers for local police, fire
department, poison control, after hours
medical advice and other appropriate X
emergency numbers must be posted near all
telephones.
(4) Operative flashlights sufficient in number
X
are readily available to staff
(5)(a) Evacuation drill occurs monthly under
varying conditions, is retained 2 years 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
Umbrella Safety
Yes No N/A Corrective Actions/Comments
419-400-0200
(5)(b) Vehicle has insurance policy, is smoke X
free, safe operating condition, and has first
aid kit and fire extinguisher 2-A:10-BC
(1)(b)(A) Each vehicle used to transport a X
child in care must be: properly registered,
covered by an insurance policy in full force
and effect, maintained in safe operating
condition, and smoke-free.
(3) If a child-caring agency has a swimming X
pool on the premises that is accessible to
children in care or if a child-caring agency
plans to have children in care engage in
swimming, the child-caring agency must
have and adhere to policies and procedures
that address, at a minimum, providing
P a g e 13 | 28
Form Rev. 04/18/2023
disclosures and obtaining consents,
assessing swimming ability of children in
care, and ensuring the safety of pool access.
(4)(a) The program protects children from X
potentially harmful items and materials.
(4)(b) Direct supervision of children who do X
not have the ability to adjust and control
water temperature
(4)(c) Light fixtures have protective covers X
unless designed to be used without one
Medication
Yes No N/A Corrective Actions/Comments
419-470-0100
(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
written order signed by a physician or
qualified medical professional. A written X
order, signed by a physician or qualified
medical professional, is also required before
a restriction on diet or physical activity is
imposed.
(7)(c) Medications are inaccessible to
children and stored behind at least two
X
locking mechanisms. This does not apply to
Naloxone.
(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:
(a) name
(b) description
(c) dates and times X
(d) missed doses
(e) medication disposed
(f) method of administration
(g) ID of person administering
P a g e 14 | 28
Form Rev. 04/18/2023
(h) possible adverse reactions
(i) medication taken outside facility
Extracurricular, Enrichment, Cultural &
Social Activities Yes No N/A Corrective Actions/Comments
419-470-0110
(2) Children have ongoing opportunities to X
participate in at least one age-appropriate or
developmentally appropriate activity
Minimum Staffing Requirements
Yes No N/A Corrective Actions/Comments
419-470-0130
(1)&(2) Supervision is adequate for the type X
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
30 months to ˃ 6 years 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 X
additional staff immediately available with
max response time of 30 minutes
(5) There is at least one on-site employee X
authorized to apply the reasonable and
prudent parent standard
Sleeping Arrangements
Yes No N/A Corrective Actions/Comments
419-470-0140
(1) Children are in separate bedrooms than X
adults, unless parent and child, or there is
written approval from guardian/parent and
licensing coordinator
(2) There is adequate supervision of children X
when sleeping
(3) When assigning bedrooms a residential X
care agency must consider all of the
following:
(a) Chronological age
(b) Developmental age
(c) Gender identity
(d) Personal history, including medical,
mental health, behavioral health, and past
adverse experiences including any physical
P a g e 15 | 28
Form Rev. 04/18/2023
or sexual abuse
Northpoint Day Treatment and Edwards Day Treatment
Physical Plant Yes No N/A Corrective Actions/Comments
419-400-0090(3)(a)Foster Rights Posted (if children in DHS custody) X
419-400-0100(1) Sufficient safe space, equipment, and office equipment. X
419-430-0030(8)(e) Classrooms and school buildings adequate in size and
X
arrangement for programs offered
419-400-0230(12) License is posted in common area at each facility X
419-430-0030(2) Buildings are clean and in good repair X
419-430-0030(3) Rooms are free of harmful drafts, odors, and excessive
X
noise
419-430-0030(4) Rooms are adequate in size and arrangement X
419-430-0030(5) System provides a continuous supply of hot and cold
X
water
419-430-0030(7) Building is well ventilated and room temperature is within
X
a normal comfort range
Room and Space Requirements Yes No N/A Corrective Actions/Comments
419-430-0030
(8)(b) Laundry is separate from food storage, kitchen, and dining rooms X
(8)(c) Separate storage areas are provided for food, kitchen supplies,
utensils, clean linens, soiled linens and clothing, cleaning supplies and
X
equip, poisons, chemicals, outdoor recreational and maintenance
equipment
(8)(f) Time out rooms have adequate space, heat, light and ventilation and
X
is not capable of locking
(8)(g) Recreational activity area is protected from vehicles and other Northpoint Day Treatment: The fenced backyard area has
hazards and of a size and availability appropriate to the age and needs of many holes in the yard that is unsafe. A large tree has been
children in care X removed that left a large hole. The program shall ensure the
area is made safe for all clients.
Room and Space Requirements Yes No N/A Corrective Actions/Comments
Bathrooms
419-430-0030(8)(a)
(A) 1:15 ratio for toilets X
(B) 1:2 ratio for sinks to toilets. Hand-washing sink not used for food prep X
(C) Hot and cold running water, soap, and approved hand drying options X
(D) Individual privacy X
(E) Permanently wired fixtures X
(F) Window covering X
(G) Mirror, permanently affixed X
(H) Adequate ventilation X
Food Service Areas Yes No N/A Corrective Actions/Comments
P a g e 16 | 28
Form Rev. 04/18/2023
419-430-0030(8)(d)
(A) Areas used for storage, food preparation, and dish washing are
X
separate from child-caring areas
(B) Walls, floors are easily cleanable X
(C) Equipment and utensils are easily cleanable, durable, nontoxic, and
X
kept clean
(D) Equipment is easy to clean beneath, between and behind X
Food Services
Yes No N/A Corrective Actions/Comments
419-430-0060
(1)(a) Meals are arranged daily, consistent with normal mealtimes that
X
occur during the hours of operation
(b) Menus are prepared in advance in accordance with USDA guidelines,
X
provide a variety of foods and are adjusted for seasonal changes.
(b) Menus are maintained for at least 6 months X
(c) Drinking water is freely available X
(2)(a) Food is stored, prepared & served in a sanitary manner X
(2)(c) & (d) Food products are obtained from commercial suppliers
(exception of fruits & vegetables), unpasteurized juice is prohibited, and X
only Grade A pasteurized and fortified milk in appropriate container.
(2)(e) Children are supervised when in the food-preparation area X
Day Treatment Safety Yes No N/A Corrective Actions/Comments
419-430-0070
(2)(a) Written emergency plan X
(2)(b) Telephone numbers for local police and fire are posted near all X
telephones
(2)(c) Operative flashlights sufficient in number are readily available to staff X
(3)(a) Evacuation drill occurs monthly under varying conditions, is retained X
2 years and contains:
(A) identity 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
Umbrella Safety Yes No N/A Corrective Actions/Comments
419-400-0200
(5)(b) Vehicle has insurance policy, is smoke free, safe operating X
condition, and has first aid kit and fire extinguisher 2-A:10-BC
(1)(b)(A) Each vehicle used to transport a child in care must be: properly X
registered,
covered by an insurance policy in full force and effect, maintained in safe
operating condition, and smoke-free.
P a g e 17 | 28
Form Rev. 04/18/2023
(3) If a child-caring agency has a swimming pool on the premises that is X
accessible to children in care or if a child-caring agency plans to have
children in care engage in swimming, the child-caring agency must have
and adhere to policies and procedures that address, at a minimum,
providing disclosures and obtaining consents, assessing swimming ability
of children in care, and ensuring the safety of pool access.
(4)(a) The program protects children from potentially harmful items and X
materials.
(4)(b) Direct supervision of children who do not have the ability to adjust X
and control water temperature
(4)(c) Light fixtures have protective covers unless designed to be used X
without one
Medication
Yes No N/A Corrective Actions/Comments
419-430-0090
(2)&(5)(e) Medications have a prescription and are stored in the original
X
container with prescription label
(5) Medications are kept in locked storage X
(6) Medications are disposed in accordance with state and federal law X
(7) Written record of the disposal of medications is maintained (description,
X
name, reason, method, staff & witness signature)
Staff Qualifications and Minimum Staffing Requirements
Yes No N/A Corrective Actions/Comments
419-430-0020
(1) Teachers are licensed in accordance with Teachers Standards and
X
Practices Commission
(2) A qualified clinical supervisor directs the clinical program and
X
supervises clinical staff
(3) Mental health service delivery staff meet the qualifications in OAR 309-
X
022-0125
(4) Sufficient QMHP and other staff to meet the severity and acuity of
children served. Does not exceed 1:12 QMHP
X
Current Ratios__________________
413-215-0001(5)(f) Ensures safety and adequate supervision X
413-215-0001(5)(c) Engages in and applies appropriate behavior
X
management techniques
Parry Center, Children’s Farm Home and Sender House
Personnel Files
Yes No N/A Corrective Actions/Comments
419-400-0120
Staff Name/Position X
P a g e 18 | 28
Form Rev. 04/18/2023
(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
X
and documented
(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
Requirements (30 days) Yes No N/A Corrective Actions/Comments
419-400-0120(4)
Parry Center: Staff did not complete orientation training on agency policies and
(a) Agency policies and procedures X procedures within 30 days of hire. The program shall ensure all staff complete all
orientation trainings within 30 days of hire.
(b) Ethical and professional guidelines X
Children’s Farm Home: Suicide prevention and intervention training was not completed
(c) Suicide prevention and intervention X within 30 days of hire. The program shall ensure all staff complete all orientation trainings
within 30 days of hire.
(d) Attributes of population served X
(e) & (5)(a) to (c) Mandatory reporting that
includes:
(a) legal definition of child abuse in ORS Parry Center: Staff did not complete orientation training on mandatory reporting within 30
418.257 and 419B.005 X days of hire. The program shall ensure all staff complete all orientation trainings within 30
(b) legal responsibility to immediately report days of hire.
(c) legal responsibility to report is personal to
the employee
Parry Center: Staff did not complete orientation training on privacy laws within 30 days of
(f) Privacy laws X hire. The program shall ensure all staff complete all orientation trainings within 30 days of
hire.
Parry Center: Staff did not complete orientation training on emergency procedures within
(g) Emergency procedures X 30 days of hire. The program shall ensure all staff complete all orientation trainings within
30 days of hire.
New Employee Orientation
Residential (Prior to working alone and
Yes No N/A Corrective Actions/Comments
within 30 days)
419-470-0120(1)
(a) Discipline and behavior management
X
including de-escalation, crisis prevention,
P a g e 19 | 28
Form Rev. 04/18/2023
positive behavior management, and
disciplinary techniques that are non-punitive
in nature
(b) CPR and First Aid sufficient to retain a
X
current certification
(c) Universal precautions and hygiene X
Children’s Farm Home: Staff did not complete application on the reasonable and prudent
(d) Application of the reasonable and
X parent standard training within 30 days of hire. The program shall ensure all staff
prudent parent standard
complete all orientation trainings within 30 days of hire.
(e) Training on the agency’s policy on Children’s Farm Home: Staff did not complete training on the agency’s policy on suicide
suicide prevention and suicide risk X prevention and suicide risk assessment tool within 30 days of hire. The program shall
assessment tool ensure all staff complete all orientation trainings within 30 days of hire.
Crisis Intervention Training Standards
and Certification Yes No N/A Corrective Actions/Comments
419-400-0160(4) (as applicable)
(a)Complete a minimum of 12 hours of initial
training in person from a certified instructor,
including but not limited to a minimum of six
hours of training focused on positive
X
behavior support, nonviolent crisis
intervention and other methods of
nonphysical intervention to support children
in care during a crisis
(d) Receive a certificate that states:
(A) The dates during which the certification
is current
(B) The type of restraint which the individual
is certified to perform if applicable
(C) The type of training the individual is
certified to conduct if applicable X
(D) Any special endorsements earned by the
individual
(E) The level of training
(F) The name of the certified instructor who
conducted the training and administered the
assessment of proficiency.
(e) A certification issued:
(A) Must be personal to the individual
certified by the training provider X
(B) May be valid for no more than two years
with recertification
Ongoing Training Yes No N/A Corrective Actions/Comments
P a g e 20 | 28
Form Rev. 04/18/2023
419-470-0070(2)(b) Employees who handle
food served to children have a valid food X
handler’s card
419-400-0200 (1) 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)
419-470-0120 (2)(a) Environmental
X
emergencies
419-470-0120 (2)(b) Universal Precautions X
419-470-0120 (2)(c) Discipline and Behavior
X
Management
419-470-0120 (2)(d) Agency’s policy on
X
suicide prevention and risk assessment tool
419-470-0120 (3) Staff providing direct care
must maintain current CPR/First Aid X
certification
419-470-0120 (4) Designated staff
authorized to apply reasonable and prudent
X
parent standard are trained in application of
the standard
419-400-0120(5) Mandatory reporting
(annually) that includes:
(a) legal definition of child abuse in ORS Parry Center: One staff did not complete mandatory reporting training within 30 days of
418.257 and 419B.005 X hire. The program shall ensure all staff complete mandatory reporting training within 30
(b) legal responsibility to immediately report days of hire.
(c) legal responsibility to report is personal to
the employee
419-400-0160(4)(b) Receive continuing
education (as applicable on crisis
X
intervention training) from a certified
instructor on an annual basis
Northpoint Day Treatment and Edwards Day Treatment
Personnel Files
Yes No N/A Corrective Actions/Comments
419-400-0120
Name X
Position X
P a g e 21 | 28
Form Rev. 04/18/2023
(3)(g) Date of Hire X
(3)(a) record of education, training, and previous employment X
(1)(b) & (3)(b) reference checks complete and documented X
(1)(a) & (3)(c) Background check was completed and documented X
(3)(d) Annual performance evaluations X
(3)(f) Record of personnel actions X
(3)(g) Termination date, reason for termination X
(3)(h) Current job description (1)(c) Employee meets minimum
X
qualifications stated in current job description
New Employee Orientation- Umbrella Requirements (30 days)
Yes No N/A Corrective Actions/Comments
419-400-0120(4)
(a) Agency policies and procedures X
(b) Ethical and professional guidelines X
Northpoint: Two staff did not complete suicide prevention
and intervention training within 30 days of hire. The program
(c) Suicide prevention and intervention X
shall ensure staff complete all orientation trainings within 30
days of hire.
(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, Edwards: One staff did not complete Mandatory reporting
chapter 106, section 36 X training within 30 days of hire. The program shall ensure staff
(b) legal responsibility to immediately report complete all orientation trainings within 30 days of hire.
(c) legal responsibility to report is personal to the employee
(f) Privacy laws X
(g) Emergency procedures X
Crisis Intervention Training Standards and Certification
Yes No N/A Corrective Actions/Comments
419-400-0160(4) (as applicable)
(a)Complete a minimum of 12 hours of initial training in person from a
certified instructor, including but not limited to a minimum of six hours of
training focused on positive behavior support, nonviolent crisis X
intervention and other methods of nonphysical intervention to support
children in care during a crisis
(d) Receive a certificate that states:
(A) The dates during which the certification is current
(B) The type of restraint which the individual is certified to perform if
applicable
(C) The type of training the individual is certified to conduct if applicable X
(D) Any special endorsements earned by the individual
(E) The level of training
(F) The name of the certified instructor who conducted the training and
administered the assessment of proficiency.
P a g e 22 | 28
Form Rev. 04/18/2023
(e) A certification issued:
(A) Must be personal to the individual certified by the training provider
(B) May be valid for no more than two years with recertification X
Ongoing Training Yes No N/A Corrective Actions/Comments
419-430-0060(2)(b) Employees who handle food served to children have
X
a valid food handler’s card
419-400-0120(5) Mandatory reporting (annually) that includes:
(a) legal definition of child abuse in ORS 418.257 and 419B.005
X
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to the employee
419-400-0200(1) Employees transporting children meet the driver
requirements (current driver’s license, insurance, trained in emergency
X
procedures & behavior management, and training for 15+ passenger
vans if applicable)
419-400-0160(4)(b) Receive continuing education (as applicable on crisis
X
intervention training) from a certified instructor on an annual basis
Parry Center, Children’s Farm Home and Sender House
Children’s Records Yes No N/A Corrective Actions/Comments
Health Services
419-470-0090
(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)
(4)(a) to (f) Medical exams (3 in first year of
life, 2,4,6,9,14) X
(g) Have a physical examination within the
first 60 days after admission of a child in
care. Documentation of a physical X
examination having occurred within the
calendar year will meet this requirement.
Consents Yes No N/A Corrective Actions/Comments
P a g e 23 | 28
Form Rev. 04/18/2023
419-470-0160(1)
(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
(e) Allow access as defined in 419-400-0230
X
& 0240
(f) Impose a dress code X
(g) Apply the reasonable and prudent parent
X
standard
Disclosures
419-470-0160(2) Yes No N/A Corrective Actions/Comments
Parent/guardian has 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 request X
Authorizations
Yes No N/A Corrective Actions/Comments
419-470-0160(3)
(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
419-400-0190(1) Yes No N/A Corrective Actions/Comments
Summary sheet contains 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
P a g e 24 | 28
Form Rev. 04/18/2023
(e) The name, 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
X
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)
Service Planning
Yes No N/A Corrective Actions/Comments
419-470-0170(2)
(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 be X
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
Yes No N/A Corrective Actions/Comments
419-470-0170(3)
(a) Services are documented, progress
X
toward achieving goals is tracked
(c) Discharge 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 X
(D)Summary of the child’s participation in the
program and progress achieved
(E)Results of evaluations
(F)Recommendations regarding services
(G)Discharge destination
(e) Follow up services X
P a g e 25 | 28
Form Rev. 04/18/2023
(f) Incident Reports X
Records Relating to Restraint &
Yes No N/A Corrective Actions/Comments
Involuntary Seclusion
419-400-0180 (12) Records X
419-400-0180(13)(e) Each child caring
agency shall provide notice regarding how to
Parry Center, Children’s Farm Home and Sender House: The programs do not provide
access the quarterly reports to the parents or
notice regarding how to access the quarterly reports to the parents or guardians of
guardians of children in care in the program. X
children in care. The program shall ensure the parents or guardians of children in care
The child caring agency shall provide the
are provided notice regarding how to access the quarterly reports.
notice upon the child in care’s admission and
at least two times each year thereafter.
Parry Center, Children’s Farm Home and Sender House: The programs do not provide
419-400-0190(1) Information provided to
information to children in care relating to restraint and involuntary seclusion. The program
children in care relating to Restraint & X
shall ensure the information described in OAR 419-400-190 is provided to children in care
Involuntary Seclusion
relating to restraint and involuntary seclusion.
Financial Records
Yes No N/A Corrective Actions/Comments
419-470-0170(4)
Records contain date, amount, source,
X
purpose, signatures
Personal Possessions Records
Yes No N/A Corrective Actions/Comments
419-470-0170 (5)
Individual written inventory of all personal
possessions is maintained and updated as X
needed
Records and Documentation
Yes No N/A Corrective Actions/Comments
419-400-0140
(1) Stored safely X
(2) Permanent, legible, dated, and signed X
(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
P a g e 26 | 28
Form Rev. 04/18/2023
Northpoint Day Treatment and Edwards Day Treatment
Children’s Records Yes No N/A Corrective Actions/Comments
Name of Child X
Date of admission X
Medication
Yes No N/A Corrective Actions/Comments
419-430-0090
(3) Medical treatments, special diets, physical therapy, physical aides, or
limitations have a written order signed by a physician or qualified medical X
professional.
(4) Self-administration is approved in writing by Physician, recommended
X
by agency, and monitored by staff or guardian.
(9) If applicable, there is documentation of the continuing evaluation of
X
the ability of the child to self-administer medication
(8) Medication record X
Records Relating to Restraint & Involuntary Seclusion Yes No N/A Corrective Actions/Comments
419-400-0180 (12) Records X
The program does not provide notice regarding how to
419-400-0180(13)(e) Each child caring agency shall provide notice
access the quarterly reports to the parents or guardians of
regarding how to access the quarterly reports to the parents or guardians
children in care. The program shall ensure the parents or
of children in care in the program. The child caring agency shall provide X
guardians of children in care are provided notice regarding
the notice upon the child in care’s admission and at least two times each
how to access the quarterly reports to the parents or
year thereafter.
guardians of children in care.
The program does not provide information to children in care
relating to restraint and involuntary seclusion. The program
419-400-0190(1) Information provided to children in care relating to
X shall ensure the information described on OAR 419-400-
Restraint & Involuntary Seclusion
0190 is provided to children in care relating to restraint and
involuntary seclusion.
Records and Documentation
Yes No N/A Corrective Actions/Comments
419-400-0140
(1) Stored safely and are available for inspection by Dept. X
(2) Permanent, legible, dated, and signed X
(3)&(4) Uniform in organization, readily identifiable and accessible,
current, and complete, containing all required info. No eraser tape or X
white out.
(7) Permanent registry for each child includes:
Name
Gender
X
Birth date
Names, addresses of parents or guardians
Dates of admission
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Form Rev. 04/18/2023
Placement upon discharge
419-400-0100 (2) Licensing Umbrella Rules: Resources Required. (2) A child-caring agency must employ or contract for a sufficient number of
competent and qualified employees to perform the functions regulated by these rules and to provide adequate care, safety, protection, and
supervision of the children in care and families the child-caring agency serves.
During staff interviews and subsequent record review, it was discovered one client was unable to take a shower on two separate occasions in a two-
week period due to an insufficient number of staff. There were numerous notes that the client smelled and was not clean. Furthermore, there was
an incident in which a staff was in a physical altercation with a client in the backyard of a unit and called for staff support three times. There were not
enough staff on campus to respond to the call. It was reported by staff that low staffing is a constant issue. The program shall ensure a sufficient
number of staff are on campus to provide adequate care, safety, protection and supervision of the clients in care.
Licensing Coordinator’s Signature: ________________________ Date: _9_.1__9_.2_0_2_3___________
Manager Review: ______________________________________ Date: _9_-_1_8_-2__0_2_3_ ________
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Form Rev. 04/18/2023

agency_name: Trillium Family Services (TFS)

program_type: (RC) Residential Care Programs

report_type: License Renewals

view_code: RC

facility_type: Residential Care

licensee: Trillium Family Services

executive_director: Jamie Vandergon

board_chairperson: Eric Hunter

licensing_coordinator: Aubrey Kelly

other_regulatory_agencies: Oregon Health Authority

program_description:
Parry Center and Children's Farm Home serve children between the ages of 5 and 17 who are struggling with mental
health challenges and are in need of 24-hour residential treatment. The programs provide secure and nurturing healing environments within locked
facilities. Clients have access to fenced and open recreations areas, therapeutic activities aimed at increasing social and emotional well-being,
opportunities for home visits and community outings if appropriate.
Edwards Day Treatment is a day treatment program located in the Portland area. Teachers are from the Portland Public School District.
North Point Day Treatment is located on the Children's Farm Home Campus and is a collaborative program that specializes in individual, family, and
group therapy; group skills training, psychiatric oversight; treatment planning; care coordination; and educational services to students 5-18 who
experience emotional or behavioral difficulties impacting their ability to be successful in school and home environments
Sender House young adult independent living group home is a voluntary community based residential home. It serves youth with significant mental
health concerns that are being transitioned out of or being diverted from a hospital, residential, corrections, or foster care system. The program is
designed to help young people transition into adulthood by meeting their developmental, psychosocial, and physical needs as emerging adults with
significant mental health needs.

program_services:
Parry Center and Children's Farm Home- Psychiatric Residential Treatment Services (PRTS), sub-acute and secure inpatient.
Edwards Day Treatment and Northpoint Day Treatment -Psychiatric Day Treatment.
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Sender House - Transitional Age Youth Program: Residential Treatment Home.

capacity_age_range: Parry Center - 36 capacity, age range 5-18. Edwards Day Treatment - 48 capacity, age range 5-18. Children's Farm Home - 48 capacity, age range 11-18. Northpoint Day Treatment - 24 capacity, age range 5-18. Sender House - 4 capacity, age range 17-24.

average_length_of_stay: Residential - 85 days. Day treatment - 35 days.

average_daily_population_served: Parry Center and Edwards Day Treatment - 48. Children's Farm Home and Northpoint Day Treatment - 51.

number_of_children_served_annually: 480 clients

use_of_seclusion_or_restraint: Yes - CPI

interviews_observations:
Parry Center client: They have been at the program since 06.27.2023. Their favorite staff is everyone on the front end shift of the week and some
on the back end shift of the week. They feel comfortable talking with staff. The food is ok, they like the cheesy rice and bar-be-que are their favorite.
They get along with the other clients. There are a lot of groups every day. They haven't been in a hold since being at the program. They see their
therapist every week. They have family calls and visits. The program does community outings. They really like art and wouldn't change anything
about the program.
Edwards Day Treatment client: They have been at the program for a month. They have been a lot of different schools, they really like it here. They
see their therapist one time a week. The food is good, the burrito bowls are their favorite. They get along with the other clients. There are a lot of
staff they can talk to. Their favorite staff is Phillip. They have activities on Wednesdays. No one has put their hands on them since being at the
program.
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Edwards Day Treatment staff: They are a skills trainer and have been since November 2022. They attended 1 full week of academy training which
included 2 full days of Crisis Prevention Institute (CPI) training. Training included in how to lead a group, documentation, how to talk to clients,
privacy training and mandatory reporting training. Their supervisor check ins with them every day. They lead treatment groups which include art
groups, yoga and a lot of physical activities. Staff meet every week with the therapists to staff the clients. Clients are never left unattended, there are
four kids in their classroom. Communication is good, they know all the other staff. Staff support one another. It can be hard when staff are out,
additional responsibilities tend to fall on the skills trainer.
Sender House client: They have been at the program for over a month, they were previously at Children's Farm Home, Albertina Kerr Centers and
Unity. They are going to be starting college soon. The staff are nice and respectful. The clients make their own meals. They feel safe here.
Northpoint client: They have been the program for one month. They see their therapist two times a week. The food is good, but they would change
the cheese if they could. Staff are always available to check in with. They really like school at the program and how they can complete credits. They
have family therapy one time a week. They like clients are allowed to have snacks and take naps. Staff are really cool. They feel safe here.
Children's Farm Home client: They have been at the program for almost two months. They like they can go outside anytime here. They have been
on outings and really enjoys those. They have visits and phone calls with their family and have family therapy one time a week. They are working on
their goals and feel safe here. They have been in one hold at the program. They like the food and enjoy the chicken strips and pizza the most. Their
favorite staff is Mark. Mark is friendly and open. If they could change something at the program it would be to have animals in the milieu.
Children's Farm home client: They have been at the program for two months. The staff really shine. The food is ok, there is a lot of variety. They
have visits and phone calls with their family. They don't feel like they have made progress here. They wish they had longer therapy sessions. They
feel safe here.
Children's Farm home staff: 6 Children's Farm Home staff were interviewed. The following is a summary of the interviews. Staff consistently
reported more staff are needed on campus. Staff reported when they call for additional staff support during an incident, not enough staff respond, or
no staff respond at all. Staff reported feeling like they are keeping clients engaged in treatment and keeping them on track. Staff reported some are
not able to take their breaks due to not having enough staff to cover. Staff reported communication from leadership has improved. Leadership has
been doing meetings twice a week with staff, and staff reported the meetings are helpful as leadership can hear their concerns.

changes_in_last_two_years:
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The most significant changes have been adapting to COVID and the lingering impact. Prior to COVID, Parry Center and Edwards served approximately
67 clients on any given day (as opposed to the 48 listed above) and Children's Farm Home and Northpoint served approximately 68 clients on any
given day (as opposed to the 51 cited above). The reduction is largely due to staffing challenges. The teams are slowly building back to pre-covid
staffing.
Other changes are a re-distribution of levels of care. At Parry Center, they are limiting the number of Secure Inpatient (SIP) youth to 12, where it was
frequently at 15-16 in the past few years. This has caused a corresponding increase in the number of PRTS youth served. At Children's Farm Home,
they are limiting the number of SIP youth to 20, where it was frequently at 28 in prior years. As with Parry Center, this has caused a corresponding
increase in the number of PRTS youth served.
Additionally, in one program on each campus, we have incorporated PRTS and Subacute services into a program that was previously exclusively
SIP. Edwards Day Treatement has had a good number of staff turn over as well as the child psychiatrist turn over within the last 6-months. The
program had to adjust to the 'new normal' as COVID has started to become less of an issue.
At Children's Farm Home, the Redwood unit was moved to a blended unit with both SAIP and PRTS clients. The Powers unit was shut down and
re-opened in February 2022. The Sequoia unit has moved away from traditional psychoeducation groups and put more focus on activities that are
passionate to engage clients in skill practice within those activities. The Cummings unit has gone from a low census of 6 clients to 12 clients.
At Parry Center, the COVID-19 pandemic changed many aspects of residential treatment. Finding in person after-care services, particularly at the
intensive outpatient level of care, has been increasingly challenging. Additionally, changes have continued from the impact of the Senate Bill.
Documentation requirements take up a much greater amount of time both in training and auditing. There have been some leadership changes.
There has been a significant amount of turnover within the past two years.

excerpt:
Documents as indicated on form titled
“Required Financial Documents and
Information” The program has not submitted their tax compliance certificate. The program is actively
working to obtain the certificate. The program shall ensure their tax compliance certificate
is obtained and submitted to Licensing.

excerpt:
&(c) Buildings are
smoke free, clean and in good repair Parry Center
North 1: One client’s bedroom was messy and had water on the floor. Room A5 and the
sensory room were messy and had client belongings all over the floor. The program shall
ensure all buildings are clean.
Children’s Farm Home
Sequoia: Bedrooms number 2 and 9 were messy and had belongings all over the floor.
Cummings: Bedroom number 5 was messy and had belongings all over the floor. One
bathroom had the word “fuck” carved in the wall.
The program shall ensure all buildings are clean and in good repair.

excerpt:
(8)(g) Recreational activity area is protected from vehicles and other
hazards and of a size and availability appropriate to the age and needs of
children in care Northpoint Day Treatment: The fenced backyard area has
many holes in the yard that is unsafe. A large tree has been
removed that left a large hole. The program shall ensure the
area is made safe for all clients.

excerpt:
(a) Agency policies and procedures Parry Center: Staff did not complete orientation training on agency policies and
procedures within 30 days of hire. The program shall ensure all staff complete all
orientation trainings within 30 days of hire.

excerpt:
(c) Suicide prevention and intervention Children’s Farm Home: Suicide prevention and intervention training was not completed
within 30 days of hire. The program shall ensure all staff complete all orientation trainings
within 30 days of hire.

excerpt:
(e) & (5)(a) to (c) Mandatory reporting that
includes:
(a) legal definition of child abuse in ORS
418.257 and 419B.005
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee Parry Center: Staff did not complete orientation training on mandatory reporting within 30
days of hire. The program shall ensure all staff complete all orientation trainings within 30
days of hire.

excerpt:
(f) Privacy laws Parry Center: Staff did not complete orientation training on privacy laws within 30 days of
hire. The program shall ensure all staff complete all orientation trainings within 30 days of
hire.

excerpt:
(g) Emergency procedures Parry Center: Staff did not complete orientation training on emergency procedures within
30 days of hire. The program shall ensure all staff complete all orientation trainings within
30 days of hire.

excerpt:
(d) Application of the reasonable and
prudent parent standard Children’s Farm Home: Staff did not complete application on the reasonable and prudent
parent standard training within 30 days of hire. The program shall ensure all staff
complete all orientation trainings within 30 days of hire.

excerpt:
(e) Training on the agency’s policy on
suicide prevention and suicide risk
assessment tool Children’s Farm Home: Staff did not complete training on the agency’s policy on suicide
prevention and suicide risk assessment tool within 30 days of hire. The program shall
ensure all staff complete all orientation trainings within 30 days of hire.

excerpt:
(c) Suicide prevention and intervention Northpoint: Two staff did not complete suicide prevention
and intervention training within 30 days of hire. The program
shall ensure staff complete all orientation trainings within 30
days of hire.

excerpt:
(e) & (5)(a) to (c) Mandatory reporting that includes:
(a) legal definition of child abuse ORS 419B.005, Oregon Laws 2016,
chapter 106, section 36
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to the employee Edwards: One staff did not complete Mandatory reporting
training within 30 days of hire. The program shall ensure staff
complete all orientation trainings within 30 days of hire.

excerpt:
Each child caring
agency shall provide notice regarding how to
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. Parry Center, Children’s Farm Home and Sender House: The programs do not provide
notice regarding how to access the quarterly reports to the parents or guardians of
children in care. The program shall ensure the parents or guardians of children in care
are provided notice regarding how to access the quarterly reports.

excerpt:
Information provided to
children in care relating to Restraint &
Involuntary Seclusion Parry Center, Children’s Farm Home and Sender House: The programs do not provide
information to children in care relating to restraint and involuntary seclusion. The program
shall ensure the information described in OAR 419-400-190 is provided to children in care
relating to restraint and involuntary seclusion.