facility_name: Rimrock Trails Treatment Services

summary: License Renewals - 5 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care
Licensee: Rimrock Trails Treatment Services Date of site visit: June 7 & 8, 2022
Executive Director: Erica Fuller Licensing Coordinator: Robin DuVal
Board Chairperson: Monica Elsom
Other Regulatory or Accrediting Agencies: Carrie Wouda with Oregon Health Authority (OHA) participated during this review for OHA review.
Program Compliance: The program was found to be compliant or will be compliant with OAR 413-215-0001 to 413-215-0131, Licensing Umbrella
Rules, and OAR 413-215-0501 to 413-215-0586, Licensing Residential Care Agencies Rules. Personnel records were reviewed and compliance with
required background checks was documented for employees in all programs.
Program Description(s): Rimrock is a licensed Residential Care program, also licensed by Oregon Health Authority, which provides services to
youth with co-occurring mental health and substance use disorders.
Program type and services: The program provides 24-hour structured care and the opportunity for teens to achieve distance from negative influences
withing their social environment. While stabilizing and moving through the stage of early abstinence, the program helps teens build distress tolerance,
emotion regulation, and the interpersonal skills necessary to lead a more positive and productive life. The campus provides a safe and supportive
therapeutic environment conducive to learning, empowerment, and change. The program is intentionally co-ed to replicate a real-world environment
and provide the opportunity to build interpersonal relationship skills. All counseling and treatment services provided by Rimrock Trails are guided by
a trauma-informed philosophy that embraces the principles of safety, compassion, collaboration, support, and empowerment. Rimrock blends
evidence-based practices from medicine and psychology with historically proven addiction treatment methods. Their methods are strength-based,
neuro-biologically-grounded, and trauma-informed. The program provides a learning center for school credit recovery and enrichment activities such
as equine therapy, a low ropes course, and a climbing wall. Adolescent Treatment Aides (TAs) are the program’s daily floor staff that support clients
in day-to-day activities. TAs are Certified Peer Recovery Support Specialists, which means they are individuals who are in recovery from substance
use or co-occurring mental health disorders. They have a shared understanding and respect for what clients are going through as they have
experienced similar struggles in their own lives. They can provide clients support and share the tools, skills, and education they learned in their
recovery to help them transform their life. They also facilitate groups, provide 1:1 supported counseling, participate with and engage in program
activities with clients, monitor for safety, facilitate Restorative Circles, respond to incidents, and supervise the program to ensure that policies and
procedures are being followed that result in daily program consistency during clients stay at Rimrock.
Rimrock Trails utilizes Collaborative Problem Solving (CPS) as a method for understanding behavior challenges in a compassionate, accurate and
non-adversarial way. Family involvement and participation is also a key component in the treatment program.
Capacity and Age Range: 24, ages 12-17
Funding sources: Division of Medical Assistance Programs (DMAP), Medicaid/Medicare, Commercial Insurances, Block Grants funding, Juvenile
Justice Flex Funds, schools and other community partners, grants, and fundraising.
Contracts and sources for referrals: OHA, Coordinated Care Organization contracts, Regence, various commercial insurance companies, OHA-
Room and Board, DMAP residential and outpatient, Deschutes County, Oregon Department of Education, Deschutes Juvenile and Central and
Eastern Oregon Juvenile Justice Consortium (COEJJC), Redmond School District, Mountain Star Relief Nursery.
Average length of stay:
July 2020 - June 2021 = 46 days
July 2021 – June 2022 = 30 days
Pre-COVID = 50 days
Average daily population served:
July 2020 – June 2021 = 8
July 2021 – June 2022 = 2
Pre-COVID = 16
Number of children served annually:
July 2020 – June 2021 = 64 clients total
July 2021 – June 2022 = 20 clients total
Pre-COVID = 115 average annually
Use of seclusion or restraint: no
Interviews: Three youth, ages 13, 14 and 17 were interviewed individually and all reported feeling safe, staff are trusting, food is good and plentiful,
no issues receiving medications as ordered, there is regular unrestricted phone time and video calls with family, and numerous recreational activities
both inside and outside the program were described. Youth shared personal examples of how the program is helping each of them, they meet weekly
with their therapist, and they feel heard and are involved in their treatment plan and goals. Least favorite things reported about the program is the
bedtime is too early (9:30pm), having the boys and girls separated, group sessions are too long (1 ½ hours), and the daily repetitiveness of the routine.
The program does well at keeping youth happy and having someone to talk to, keeping youth calm and staff providing emotional support, and handling
youth needs when having a hard time. Youth reported there was nothing that the program could improve on, other than some staff can be “annoying”.
One youth specifically stated staff are “really cool” and they were going to “miss this place” when they’re discharged.
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Two staff were interviewed individually, and both described the extensive training they received prior to the program reopening. One staff was unclear
about who to report suspected child abuse to, and this licensor provided on-the-spot training and followed up with management.* Staff meetings occur
weekly, daily contact with their supervisor, and staff feels free to express concerns, and feels heard and understood. One staff reported some growing
pains and relationship building with their supervisor, although the two are working towards the same goals of understanding each other. Staff feel the
program is adequately staffed but was challenging during a time some staff were out with COVID. When a youth enters the program, staff are expected
to read their information in the electronic system, plus there are shift change huddles and regular contact with the therapists. Staff stated youth have
regular unrestricted contact with family, including family therapy time. The program does well at having staff that really cares and wants to help youth,
program is open to making changes, and managers are approachable and receptive. Areas the program could improve on are the interpersonal
challenges among staff, more guidance on the floor “in the moment” for staff, consistent expectations and rules, and funding for program enhancement
for things like newer pool sticks for playing 8-ball. Management was recently made aware of issues with staff documentation, and management was
quick to get a training scheduled to address the concern.
*Note: In collaboration with the program and CCLP, a mandatory abuse reporting training was scheduled and occurred July 20, 2022.
Observations: The overall program is welcoming and well maintained, inside and outside including landscaping. The agency has a thorough COVID
screening process upon arrival and face masks are required for staff and visitors. The program recently installed electronic key cards throughout the
campus which has been a positive change. The keyed locks were left on as a back-up for power outages or any other malfunction. The kitchen was
clean, adequate food supply was observed in the pantry and walk-in refrigerator and freezer, and food was being prepared for lunch by the cook and
assistant. The following areas of the campus were observed to be clean and in good repair: youth dorm rooms and bathrooms; group room; male
and female milieu areas; quiet room; gym; classroom; game and weight room; art room; staff office; and medication room, as well as the administrative
building.
Program Strengths, as reported directly from the agency:
“As an agency in the last two years we have seen several significant business successes. The most significant being the ability to maintain financial
stability throughout the extended pandemic. Youth residential services suffered due to COVID 19 staffing and referral issues forced an 8-month
closure and rebuilding of the program. We were able to rebuild the program and begin a soft re-opening in April 2022. We applied for and were
awarded Measure 110 BHRN grants for Crook and Deschutes Counties where we will be working in collaborations with other community partners to
increase treatment, resources and supports for individuals with substance use disorders. Our outpatient revenue increased significantly as we
increased capacity and utilization, added administrative supports, and strengthened our community partnerships. This led to the completion of a
successful pilot program strengthening referrals from primary care physicians as well as the development of several new contracts with schools and
other social service providers. Rimrock Trails invests heavily in the initial and ongoing extensive training and supervision of all treatment staff in the
use of trauma informed clinical approaches. Our policies and procedures are regularly reviewed and done so through a trauma informed lens. The
overarching model used in our residential treatment program is Collaborative Problem Solving. Collaborative Problem Solving (CPS) is a trauma-
informed way of identifying and addressing problem behaviors in youth that varies from many traditional behavior modification models. CPS focuses
not on motivation, rewards, and consequences to shape behavior, but instead on the lagging skills and abilities that youth have in meeting the
demands of daily life place on them. By coming alongside the youth and collaboratively identifying skill deficits and then helping youth gain those
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skills, they are more likely to step into their recovery, gain intrinsic motivation, and make longer-lasting changes. Rimrock trails also conducts a number
of trauma-informed groups including DBT, Mindfulness Based Relapse Prevention, Seeking Safety, and Shame Resiliency Training. We aim to help
clients address the complex nature of their lives and trauma history. Our trauma informed groups are utilized to teach youth ways to be in their bodies,
manage their thoughts, emotion, and behaviors in an adaptive way that helps to break the cycle of their trauma response. We continually assess the
needs of our milieu and seek out training and professional consultation to guide the development of our trauma informed policies, procedures, and
programing. Through strategic planning we have focused on implementing technological solutions to improve our efficiency, reduce risk, increase
consistency and improve communication while also working to improve compliance and increasing safety. Lastly, we continue to develop and
implement an employee retention and recruitment plan that will increase job satisfaction, reduce turnover and help keep our programs staffed with
quality team members who are aligned with our mission.”
Program Challenges, as reported directly from the agency:
“Youth residential services suffered severely due to COVID 19 staffing, and referral issues forced an 8-month closure and rebuilding of the program.
Residential treatment rates continue to be inadequate and do not cover the cost to provide a true co-occurring level of residential care. Broken
community referral systems have resulted in fewer and fewer referrals to treatment and inadequate community behavioral health systems means less
kids with a substance use disorder who are in need of treatment actually receive treatment early in the course of their disorder. Therefore, youth who
are referred to residential have more acute mental health, trauma and substance use disorders than ever before. The effects of Covid and work
shortages continue to make staffing residential very challenging, often crippling. The above factors remain the major barriers we face that affect our
ability to operate at full capacity and retain a team of highly skilled, trained and qualified staff. There is increasing demand for residential services for
youth with acute mental health and behavior problems. Sometimes we feel obligated or pressure from our community partners to accept these youth,
simply because there are no other services available to them. There is a need for short term, secured residential treatment focused on stabilization
of acute mental health and behavioral symptoms that make it challenging for them to meaningfully participate and engage in Level 111.5 residential
treatment. There is an absence of transitional or safe housing for clients who complete treatment and do not have a safe and supportive home to
return to. Payers are focused on shorter residential stays. Our experience has shown that longer residential says result in more positive residential
completions and increased client satisfaction in their treatment experience. However, their outcomes post residential discharge, regardless of length
of stay in residential is more dependent on rapid access and engagement in community based outpatient services with intensive family and recovery
supports. Across Oregon, community outpatient services and supports for youth with SUD’s are sorely lacking. We continue to experience increased
difficulties with insurance companies authorizing residential treatment. Middle class families struggle to get care for their children. The family of a
young man who committed suicide last year has helped us create an endowment to help individuals access care who otherwise would not due to
financial barriers related to high deductibles or insurance which denies coverage.”
Changes that have occurred in the last 2 years, as reported directly from the agency:
“We had to close the facility once due to a COVID outbreak and then again for several months due to staffing shortage and then difficulty in recruiting
new staff. Lived experience with mental health and/or substance use disorder and recovery is a required qualification for employment in our new youth
residential program model. Our program is now 100% staffed by Peers (YSS, CRM, PSS) known as Treatment Aides. We also have Clinicians who
have lived experience. We are strategically creating a workforce of individuals who have a collective degree of empathy and resilience as a force for
good to help kids. The science is clear and tells us that the brain heals in the context of relationships and that resiliency can be developed and
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strengthened through empathy and in connection with others. We believe it is the way forward for all of us; our workforce and our clients toward
improved outcomes. We are told we are perhaps the first in the Country to take this approach. Our new residential organizational structure includes
a Residential Program Director, a Program Manager, a Medical Care Coordinator, Clinicians and Case Managers. In addition, we are recruiting from
within to include four Shift Supervisors who will provide supervision for the Treatment Aides. The Shift Supervisors will be under the direct supervision
of the Program Manager. “
Lawsuits: none
Grievances and complaints filed in the last two years: Details were provided for four documented complaints within the last two years, including
a summary, actions taken and resolutions. No further concerns.
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report, Rimrock Trails 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 are to be emailed
directly to Robin DuVal at robin.m.duval@dhsoha.state.or.us.
Exceptions: None
Changes in License: None
Summary of Review
Program and Services 413-215-0011(2) Yes No N/A Corrective Actions
Program and services are in scope of license X
Governance of the Agency 413-215-0021 Yes No N/A Corrective Actions
(1)(a) Minimum of 5 board members X
(2)(f) Formally evaluate the exec. Director’s performance annually X The agency shall submit the 2022 performance evaluation
(2)(g) Approves annual budget X once finalized.
(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 413-215-0021 Yes No N/A Corrective Actions
(3)(a) knowledge of requirements for providing care and treatment X
appropriate to programs
(3)(g) Approval from BCU X
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Discipline, Behavior Management, and Suicide Prevention 413-215-0076 Yes No N/A Corrective Actions
(3) Agency uses appropriate and positive methods of behavior management
X
and nationally recognized non-violent crisis intervention
(3)(b)(C) Agency does not use chemical and mechanical restraint (excluding
X
medically necessary devices/prescriptions)
(3)(c) Agency uses appropriate time-out rooms (adequate space, heat, light
and ventilation and is not capable of locking) and documents use in child’s X
record when applicable
(3)(e) Agency uses seclusion appropriately/consistent with policy X
(4) Agency has adequate plan in place to respond to suicidal
X
behavior/warning signs
Contractors (if applicable) 413-215-0061(6) Yes No N/A
(a) Agency ensures the contractor meets the requirements of this rule and
X
Chapter 413 division 215
(b)(B) Contract includes the following:
(i) Services provided
(ii) Contractor fees
(iii) Disclosure of information from contractor to agency
X
(iv) Lines of authority
(v) Adherence to rules, including background check
(vi) Any liability of the agency for acts of the contractor, rights of indemnity
and limitations on liability
Supplemental Information Provided by CCA Yes No N/A Corrective Actions
Documents as indicated on the form titled “Renewal Licensing Required
X
Documents”
Documents as indicated on form titled “Required Financial Documents” X
All required policies and procedures as identified in the “Umbrella Rules”
The agency shall update the Mandatory Abuse Reporting
policy, specifically regarding documentation of a report to
X authorities and including the additional abuse types
pertaining to child caring agencies. This licensor will provide
guidance with revisions.
All required policies and procedures as identified in “Residential Care Rules”
The agency shall update the Medication policies and
procedures pursuant to OAR 413-215-0551, specifically
X
regarding disposal procedures and documentation. This
licensor will provide guidance with revisions.
SB710 Requirements: Policy and Procedures; notifications to guardian and
The agency shall submit the policy and procedures, and
children in care.
notifications required to clients and guardians; and shall
OAR 413-215-0077(8)(e), (11)(e) and
X ensure clients and guardians receive the notification at intake
OAR 413-215-0078(1)
and twice yearly thereafter, and document having provided it.
This licensor will provide guidance.
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Physical Plant Yes No N/A
413-215-0046(3)(a) Foster Rights Posted (if children in DHS custody) X
413-215-0051(1) Sufficient safe space, equipment, and office equipment X
413-215-0091(12) License is posted in common area at each facility X
413-215-0001(5)(d), 0516(4(a)(I) & 0521(1) Adequate furnishings and X
personal items
413-215-0511(2)(a) &(c) Buildings are smoke free, clean and in good repair X
413-215-0511(2)(d) Rooms are free of harmful drafts, odors, and excessive X
noise
413-215-0511(2)(e) Rooms are adequate in size and arrangement X
413-215-0511(2)(f) System provides a continuous supply of hot and cold X
water to taps located throughout the facility
413-215-0511(2)(h) Building is well ventilated and room temperature is within X
a normal comfort range
413-215-0516(1) All parts of the facility ensure the safety of children X
Room and Space Requirements Bedrooms 413-215-0516(3) Yes No N/A
(a) Adequate furnishings and personal items X
(b) Separate from rooms used for dining, living, laundry, kitchen, and storage X
(c) Outside room with window allowing egress from building X
(d) Ceiling at least 90 inches X
(e) Minimum 60 SF per bed X
(f) No more than 25 if dorm style X
(g) Permanently wired fixtures X
(h) Window covering X
(i) Beds are 3 feet apart and maintained to ensure safety X
Room and Space Requirements Bathrooms 413-215-0516(4) Yes No N/A
(a)(A)&(B) 1:8 ratio for toilets and sinks X
(a)(D) Hot and cold running water, soap, and approved hand drying options X
(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 X
are disinfected & dried daily
Room and Space Requirements Kitchen 413-215-0516(6) Yes No N/A
(a) Used exclusively for storage, food preparation, dish washing and activities X
related to eating
(b) Walls, floors are easily cleanable X
(c) Equipment and utensils are easily cleanable, durable, nontoxic, and kept X
clean
(e) Equipment is easy to clean beneath, between and behind X
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Room and Space Requirements 413-215-0516 Yes No N/A
(2) There is a separate living room or lounge area – 15 SF minimum per child X
(5) There is a separate dining room with capacity for ½ of children in care and X
15 SF per child in care
(7) Laundry is separate from living areas, kitchen and dining X
(8) Separate storage areas are provided for food, kitchen supplies, utensils, X
clean linens, soiled linens and clothing, cleaning supplies and equip, poisons,
chemicals, outdoor recreational and maintenance equipment
(9) Outdoor activity area is protected from vehicles and other hazards and of X
a size and availability appropriate to the age and needs of children in care
(11) & 413-215-0076(3)(c)(C)Time out rooms have adequate space, heat, X
light and ventilation and is not capable of locking
Furnishings and Personal Items 413-215-0521 Yes No N/A
(1) There is a bed with frame, clean mattress and pillow and personal storage X
(dresser, closet)
(2) Linens are in good repair. There is a waterproof mattress cover or X
mattress. Linens are appropriate and towels and washcloths are provided
(3) Bedding is changed weekly or when soiled X
(4)&(5) Personal hygiene supplies and appropriate clothing are provided X
Food Services 413-215-0536(1)&(2) Yes No N/A
(1)(a) Meals are arranged daily, consistent with normal mealtimes that occur X
during the hours of operation
(1)(b) Menus are prepared in advance in accordance with USDA guidelines, X
provide a variety of foods and are adjusted for seasonal changes.
(1)(b) Menus are kept for at least 6 months X
(1)(c) Drinking water is freely available X
(2)(a) Food is stored, prepared & served in a sanitary manner X
(2)(c) & (d) Food products are obtained from commercial suppliers (exception X
of fruits & vegetables), unpasteurized juice is prohibited, and only Grade A
pasteurized and fortified milk in appropriate container.
Safety 413-215-0541 Yes No N/A
(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 2 X
yrs 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
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(G) problems encountered
(H) time to complete
Safety – Transportation 413-215-0541 Yes No N/A
(5)(b) Vehicle has insurance policy, is smoke free, safe operating condition, X
and has first aid kit and fire extinguisher 2-A:10-BC
Medication 413-215-0551 Yes No N/A Corrective Actions
(3)&(7)(e) Medications have a prescription and are stored in the original X
container with prescription label Note: The agency recently changed to an electronic system
(4)&(5) Herbal supplements and remedies, medical treatments, special diets, X for all medication documentation.
physical therapy, physical aides or limitations have a written order signed by
a physician or qualified medical professional.
(7)(c) Medications are inaccessible to children X
(8) Medications are disposed in accordance with state and federal law X Comment to (8): It is recommended that the collection of
medications to be disposed are stored in a separate
container in the medication cabinet and clearly marked as
“medications to be disposed”.
(9) Written record of the disposal of medications is maintained and includes: X Corrective Action: The agency did not have a medication
(a) description and amount disposal log at the time of this review, however while on-site,
(b) name the Medication Aide created a disposal log. The agency shall
(c) reason ensure disposed medications are documented on the form
(d) method with a staff and witness signature.
(e) staff & witness signature
(10) Written record of the administration of medication includes: X Corrective Action The agency shall ensure (e), (h) and (i) are
(a) name included on the record of the medication administration
(b) description record. This licensor recommended pre-set drop-down fields
(c) dates and times such as refused (R), disposed (D), out of facility (OOF), etc.
(d) missed doses This is a repeat finding from 2020.
(e) medication disposed
(f) method of administration
(g) ID of person administering
(h) possible adverse reactions
(i) medication taken outside facility
Extracurricular, Enrichment, Cultural & Social Activities
Yes No N/A
413-215-0554
(2) Children have ongoing opportunities to participate in at least one age- X
appropriate or developmentally appropriate activity
Minimum Staffing Requirements 413-215-0561 Yes No N/A
(1)&(2) Supervision is adequate for the type of program, location, age and X
type of children, ability of supervisor to respond, electronic back-up systems.
Minimum ratios are maintained: Ages 6 and older: 1:7;
Overnight (staff awake): 1:10
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(4)(a) When one staff on duty, there is additional staff immediately available X
with max response time of 30 minutes
(5) There is at least one on-site employee authorized to apply the reasonable X
and prudent parent standard
Separation of Residents 413-215-0566 Yes No N/A
(1) Children are in separate bedrooms than adults, unless parent and child, or X
there is written approval from guardian/parent and licensing coordinator
(2) There is adequate supervision of children if both males and females are X
served by the program
Personnel Files 413-215-0061 Yes No N/A Corrective Actions
Staff Name/Position X
(3)(g) Date of Hire X
(3)(a) record of education, training and previous employment X
(1)(b) & (3)(b) reference checks completed and documented X The agency shall ensure reference checks are conducted,
documented, and retained in the personnel file.
(1)(a) & (3)(c) Background check 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 qualifications
X
stated in current job description
New Employee Orientation – Umbrella Requirements (30 days)
Yes No N/A
413-215-0061(4)
(a) Agency policies and procedures X
(b) Ethical and professional guidelines X
(c) Organizational lines of authority X
(d) Attributes of population served X
(e) & (5)(a) to (c) Mandatory reporting that includes:
(a) legal definition of child abuse ORS 419B.005, Oregon Laws 2016,
chapter 106, section 36 X
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to the employee
(f) Privacy laws X
(g) Emergency procedures X
New Employee Orientation – Residential (30 days)
Yes No N/A
413-215-0556
(1)(a) Discipline and behavior management including de-escalation, crisis
prevention, positive behavior management, and disciplinary techniques that X
are non-punitive in nature
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(1)(b) Restraint and seclusion (if applicable) X
Ongoing Training Yes No N/A Corrective Actions
413-215-0536(2)(b) Employees who handle food served to children have a X Note: kitchen staff handle all food served.
valid food handler’s card
413-215-0541(5)(a) Employees transporting children have: current driver’s
license, insurance, trained in emergency procedures and behavior X
management, and training for 15+ passenger vans if applicable)
413-215-0556(2)(a) Environmental emergencies X
413-215-0556(2)(b) Universal Precautions X
413-215-0556(2)(c) Discipline and Behavior Management X
413-215-0556(3) Staff providing direct care must maintain current CPR/First
X Records of completed CPR/First Aid certifications were
Aid certification
missing. The agency shall ensure current certifications are
413-215-0556(4) Designated staff authorized to apply reasonable and maintained in personnel files. This is a repeat finding
X
prudent parent standard are trained in application of the standard from 2018 and 2020.
413-215-0061(5) Mandatory reporting (annually) that includes:
(a) legal definition of child abuse ORS 419B.005, Oregon Laws 2016,
chapter 106, section 36 X
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to the employee
Children’s Records Yes No N/A Corrective Actions
Health Services 413-215-0546
(2) Medical history obtained within 30 days (significant findings, current
immunizations, history of surgical procedures-health issues-injuries, X
allergies, dental, vision, hearing, behavioral health, and physician orders)
(2)(e) Documentation of age appropriate instruction – pregnancy prevention, Documentation of age-appropriate instruction is unmet. The
nutrition, prevention of HIV & AIDS, and prevention and treatment of sexually X agency shall ensure age-appropriate instruction occurs and
transmitted disease is appropriately documented in the child record.
(4)(a) to (f) Medical exams (3 in first year of life, 2,4,6,9,14) X
Consents 413-215-0576(1) Yes No N/A Comments
(a) Provide routine and emergency medical care X
(b) Use the discipline and behavior management system X
(c) Use restraint or seclusion (if applicable). Must specify the reasons for the
X
intervention and how staff are trained and supervised
(d) Restrict contact with persons outside of the agency X
(e) Allow access as defined in 413-215-0091 & 0101 X
(f) Impose a dress code X Comment to (f): the agency will change wording to more
align with “dress code”.
(g) Apply the reasonable and prudent parent standard X
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Disclosures
Yes No N/A
413-215-0576(2) Parent/guardian has acknowledged in writing:
(a) Information regarding personal or room searches and protocols for
X
confiscation of contraband
(b) Statement of Rights of Children and Parents/Guardians X
(c) Any policies and procedures upon request X
Authorizations 413-215-0576(3) Yes No N/A
(a) Disclose or exchange information with others X
(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 not limited to X
using motorized yard equipment, swimming, and horseback riding.
Information about Children in Care
Yes No N/A
413-215-0581(1) Summary sheet contains the following:
(a)The name, gender, date of birth, religious preference, and previous address X
(b) Name and location of previous and current school X
(c) Date of admission X
(d) Legal custody X
(e) The name, address, and telephone number of:
(A) The child in care's parents.
(B) The child in care's legal guardian, if different than the parents, and a
copy of the document that provides for his or her authority over the child X
in care.
(C) Other persons significant to child
(D) Other professionals to be involved in service planning (if applicable)
Service Planning 413-215-0581(2) Yes No N/A Corrective Actions
(b) Intake document is completed the date child accepted into care
X
(emergency placement 48 hours)
(d) Assessment is completed within 30 days and contains relevant historical
info., current behavioral observations, identified need for services, and how X
agency will provide services
The service plan shall document involvement of the child
(e) (A)&(B) Service plan within 60 days (parent, guardian and child actively
and parent/guardian in creation of the service plan as well
involved). Describes how child’s issues will be addressed, anticipated X as documented evidence that the service plan was
outcomes and reviewed by child and guardian/parent.
reviewed by the child and guardian/parent.
(e)(C)&(D) Service plan is reviewed quarterly and revised when information
X
indicates other services should be provided
Case Management 413-215-0581(3) Yes No N/A Corrective Actions
(a) Services are documented, progress toward achieving goals is tracked X The agency shall ensure the discharge planning is readily
(b)-(d) discharge planning and instructions X identifiable and accessible in the electronic record.
Page 12 of 13
(f) Incident Reports X
Financial Records 413-215-0581(4) Yes No N/A Corrective Actions
Records contain date, amount, source, purpose, signatures The agency shall create a form with all required elements to
document any financial belongings (cash, coins, gift cards,
X
etc.) of a child. This documentation must be separate from
a child’s personnel possession record.
Personal Possessions Records 413-215-0581(5) Yes No N/A
Individual written inventory of all personal possessions is maintained and
X
updated as needed
Records and Documentation 413-215-0071 Yes No N/A Corrective Actions
(1) Stored safely X
(2) Permanent, legible, dated, and signed X
(3)&(4) Uniform in organization, readily identifiable and accessible, current,
As noted above, some areas of records are incomplete.
X
and complete, containing all required info. No eraser tape or white out.
(7) Permanent registry for each child includes:
Name
Gender
Birth date X
Names, addresses of parents or guardians
Dates of admission
Placement upon discharge
Licensing Coordinator’s Signature: ________________________ Date: _8_/4__/2_0_2_2____________
Manager Review: ______________________________________ Date: _ _8_-4__-2_0_2_2_ _________
Page 13 of 13

agency_name: Rimrock Trails Treatment Services (RTTS)

program_name: Residential Adolescent SUD

board_chairperson: Monica Elsom

licensing_coordinator: Robin DuVal

program_services:
The program provides 24-hour structured care and the opportunity for teens to achieve distance from negative influences
withing their social environment. While stabilizing and moving through the stage of early abstinence, the program helps teens build distress tolerance,
emotion regulation, and the interpersonal skills necessary to lead a more positive and productive life. The campus provides a safe and supportive
therapeutic environment conducive to learning, empowerment, and change. The program is intentionally co-ed to replicate a real-world environment
and provide the opportunity to build interpersonal relationship skills. All counseling and treatment services provided by Rimrock Trails are guided by
a trauma-informed philosophy that embraces the principles of safety, compassion, collaboration, support, and empowerment. Rimrock blends
evidence-based practices from medicine and psychology with historically proven addiction treatment methods. Their methods are strength-based,
neuro-biologically-grounded, and trauma-informed. The program provides a learning center for school credit recovery and enrichment activities such
as equine therapy, a low ropes course, and a climbing wall. Adolescent Treatment Aides (TAs) are the program's daily floor staff that support clients
in day-to-day activities. TAs are Certified Peer Recovery Support Specialists, which means they are individuals who are in recovery from substance
use or co-occurring mental health disorders. They have a shared understanding and respect for what clients are going through as they have
experienced similar struggles in their own lives. They can provide clients support and share the tools, skills, and education they learned in their
recovery to help them transform their life. They also facilitate groups, provide 1:1 supported counseling, participate with and engage in program
activities with clients, monitor for safety, facilitate Restorative Circles, respond to incidents, and supervise the program to ensure that policies and
procedures are being followed that result in daily program consistency during clients stay at Rimrock.
Rimrock Trails utilizes Collaborative Problem Solving (CPS) as a method for understanding behavior challenges in a compassionate, accurate and
non-adversarial way. Family involvement and participation is also a key component in the treatment program.

average_length_of_stay: July 2020 - June 2021 = 46 days July 2021 - June 2022 = 30 days Pre-COVID = 50 days

number_of_children_served_annually: July 2020 - June 2021 = 64 clients total July 2021 - June 2022 = 20 clients total Pre-COVID = 115 average annually

use_of_seclusion_or_restraint: no Interviews: Three youth, ages 13, 14 and 17 were interviewed individually and all reported feeling safe, staff are trusting, food is good and plentiful, no issues receiving medications as ordered, there is regular unrestricted phone time and video calls with family, and numerous recreational activities both inside and outside the program were described. Youth shared personal examples of how the program is helping each of them, they meet weekly with their therapist, and they feel heard and are involved in their treatment plan and goals. Least favorite things reported about the program is the bedtime is too early (9:30pm), having the boys and girls separated, group sessions are too long (1 ½ hours), and the daily repetitiveness of the routine. The program does well at keeping youth happy and having someone to talk to, keeping youth calm and staff providing emotional support, and handling youth needs when having a hard time. Youth reported there was nothing that the program could improve on, other than some staff can be "annoying". One youth specifically stated staff are "really cool" and they were going to "miss this place" when they're discharged. Page 2 of 13 Two staff were interviewed individually, and both described the extensive training they received prior to the program reopening. One staff was unclear about who to report suspected child abuse to, and this licensor provided on-the-spot training and followed up with management.* Staff meetings occur weekly, daily contact with their supervisor, and staff feels free to express concerns, and feels heard and understood. One staff reported some growing pains and relationship building with their supervisor, although the two are working towards the same goals of understanding each other. Staff feel the program is adequately staffed but was challenging during a time some staff were out with COVID. When a youth enters the program, staff are expected to read their information in the electronic system, plus there are shift change huddles and regular contact with the therapists. Staff stated youth have regular unrestricted contact with family, including family therapy time. The program does well at having staff that really cares and wants to help youth, program is open to making changes, and managers are approachable and receptive. Areas the program could improve on are the interpersonal challenges among staff, more guidance on the floor "in the moment" for staff, consistent expectations and rules, and funding for program enhancement for things like newer pool sticks for playing 8-ball. Management was recently made aware of issues with staff documentation, and management was quick to get a training scheduled to address the concern. *Note: In collaboration with the program and CCLP, a mandatory abuse reporting training was scheduled and occurred July 20, 2022. Observations: The overall program is welcoming and well maintained, inside and outside including landscaping. The agency has a thorough COVID screening process upon arrival and face masks are required for staff and visitors. The program recently installed electronic key cards throughout the campus which has been a positive change. The keyed locks were left on as a back-up for power outages or any other malfunction. The kitchen was clean, adequate food supply was observed in the pantry and walk-in refrigerator and freezer, and food was being prepared for lunch by the cook and assistant. The following areas of the campus were observed to be clean and in good repair: youth dorm rooms and bathrooms; group room; male and female milieu areas; quiet room; gym; classroom; game and weight room; art room; staff office; and medication room, as well as the administrative building.

excerpt:
SB710 Requirements: Policy and Procedures; notifications to guardian and
children in care.
OAR 413-215-0077(8)(e), (11)(e) and
OAR 413-215-0078(1) The agency shall submit the policy and procedures, and
notifications required to clients and guardians; and shall
ensure clients and guardians receive the notification at intake
and twice yearly thereafter, and document having provided it.
This licensor will provide guidance.

excerpt: Documentation of age-appropriate instruction is unmet. The agency shall ensure age-appropriate instruction occurs and is appropriately documented in the child record.

excerpt:
(e) (A)&(B) Service plan within 60 days (parent, guardian and child actively
involved). Describes how child’s issues will be addressed, anticipated
outcomes and reviewed by child and guardian/parent.


state: OR

summary: Unannounced - 13 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Rimrock Trails Treatment Services
Executive Director: Erica Fuller
Date of Unannounced: October 12, 2022
Licensing Coordinator: Robin DuVal
Other Regulatory or Accrediting Agencies: Oregon Health Authority (OHA)
Purpose: Per OAR 413-215-0101 (1) (b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Findings Comments
2022 License Renewal Report 6/7/2022 – 6/8/2022
Further Action
Needed?
Medication 413-215-0551 (9) Written record of the disposal of medications is Yes✓No☐ The medication disposal log was observed, and the form
maintained and includes: was properly filled out meeting rule requirements.
(a) description and amount
(b) name The above noted log was kept in the medication
(c) reason manager’s office, which is a separate location from the
(d) method medication room where the bin of medications to be
(e) staff & witness signature disposed is located.
The agency did not have a medication disposal log at the time of this review, There was no tracking document within said bin,
however while on-site, the Medication Aide created a disposal log. The agency creating a risk of medication mismanagement or theft. I
shall ensure disposed medications are documented on the form with a staff and instructed the medication manager to utilize the disposal
witness signature. log form in the bin and begin tracking all medications
waiting for disposal. Repeat Finding.
It is recommended to dispose medications more
frequently to avoid any mismanagement or theft.
• This requirement is unmet and further
corrective action is needed.
Page 1 of 5
Medication 413-215-0551(10) Written record of the administration of Yes☐ No✓ Electronic medication records were observed, and
medication includes: these requirements were met.
(e) medication disposed • No further corrective action needed.
(h) possible adverse reactions
(i) medication taken outside facility
The agency shall ensure (e), (h) and (i) are included on the record of the
medication administration record. This licensor recommended pre-set drop-down
fields such as refused (R), disposed (D), out of facility (OOF), etc. This is a repeat
finding from 2020.
Personnel Files 413-215-0061(1)(b) & (3)(b) reference checks completed and Yes☐ No✓ Documentation of reference check requests (emails
documented. and calls requesting) is now included in the personnel
file as well as the completed reference checks.
The agency shall ensure reference checks are conducted, documented, and • No further corrective action needed.
retained in the personnel file.
Ongoing Training 413-215-0556(3) Staff providing direct care must maintain Yes☐ No✓ Completed CPR/First Aid certifications were observed
current CPR/First Aid certification. meeting rule requirement.
• No further corrective action needed.
Records of completed CPR/First Aid certifications were missing. The agency
shall ensure current certifications are maintained in personnel files. This is a
repeat finding from 2018 and 2020.
Health Services 413-215-0546(2)(e) Documentation of age-appropriate Yes☐ No✓ The agency has included age-appropriate instruction
instruction – pregnancy prevention, nutrition, prevention of HIV & AIDS, and topics in two recurring groups. The case managers’
prevention and treatment of sexually transmitted disease. running log identifies the date that each topic was
covered in a group session.
Documentation of age-appropriate instruction is unmet. The agency shall • No further corrective action needed.
ensure age-appropriate instruction occurs and is appropriately documented in
the child record.
Service Planning 413-215-0581(2)(e) (A)&(B) Service plan within 60 days Yes✓No☐ Records were reviewed and child involvement was
(parent, guardian and child actively involved). Describes how child’s issues will documented, however not the guardian/parent. The
be addressed, anticipated outcomes and reviewed by child and program manager stated the clinical staff had concerns
guardian/parent. involving guardians/parents due to potential privacy
concerns. Repeat Finding.
The service plan shall document involvement of the child and parent/guardian in
creation of the service plan as well as documented evidence that the service The service plan shall document involvement of the
plan was reviewed by the child and guardian/parent. child and parent/guardian in 1) creation of the service
plan, and 2) documented evidence that the service
plan was reviewed by the child and guardian/parent.
• This requirement is unmet and further
corrective action is needed.
Page 2 of 5
Case Management 413-215-0581(3)(b)-(d) discharge planning and Yes☐ No✓ Records were reviewed and discharge planning and
instructions. instructions was readily identifiable and accessible in
the record.
The agency shall ensure the discharge planning is readily identifiable and
• No further corrective action needed.
accessible in the electronic record.
Financial Records 413-215-0581(4) Records contain date, amount, source, Yes✓No☐ The newly implemented “Inventory for Safe” form was
purpose, signatures observed in a youth file. This form is used at the time of
intake; however, the agency shall have a form for
The agency shall create a form with all required elements to document any documenting any financial belongings during their stay
financial belongings (cash, coins, gift cards, etc.) of a child. This documentation in the program. Repeat Finding.
must be separate from a child’s personnel possession record.
• This requirement is unmet and further
corrective action is needed.
Governance of the Agency 413-215-0021 Yes☐ No✓ This violation has been corrected. No further action
needed.
(2)(f) Formally evaluate the exec. Director’s performance annually
The agency shall submit the 2022 performance evaluation once finalized.
Supplemental Information Provided by CCA Yes☐ No✓ This violation has been corrected. No further action
needed.
All required policies and procedures as identified in the “Umbrella Rules”
The agency shall update the Mandatory Abuse Reporting policy, specifically
regarding documentation of a report to authorities and including the additional
abuse types pertaining to child caring agencies. This licensor will provide
guidance with revisions.
Supplemental Information Provided by CCA Yes☐ No✓ This violation has been corrected. No further action
needed.
All required policies and procedures as identified in “Residential Care Rules”
The agency shall update the Medication policies and procedures pursuant to
OAR 413-215-0551, specifically regarding disposal procedures and
documentation. This licensor will provide guidance with revisions.
Supplemental Information Provided by CCA Yes☐ No✓ This violation has been corrected. No further action
needed.
SB710 Requirements: Policy and Procedures; notifications to guardian and
children in care.
OAR 413-215-0077(8)(e), (11)(e) and
OAR 413-215-0078(1)
The agency shall submit the policy and procedures, and notifications required to
clients and guardians; and shall ensure clients and guardians receive the
Page 3 of 5
notification at intake and twice yearly thereafter, and document having provided
it. This licensor will provide guidance.
Records and Documentation 413-215-0071 Yes☐ No✓ This violation has been corrected. No further action
needed.
(3)&(4) Uniform in organization, readily identifiable and accessible, current, and
complete, containing all required info. No eraser tape or white out.
As noted above, some areas of records are incomplete.
New Findings from Site Visit
None
Interview Summary
Two youth, ages 14, were individually interviewed and have been in the program approximately 21 days and 3 months, respectively. Both reported feeling safe,
gave personal examples of how this program is helping them, indicated staff and counselors are trusting, stated thar they have several phone and Zoom contacts
with parents weekly and indicated that food is good and plentiful. There was some food, i.e., apple sauce, protein shakes, that was served after the expiration
date that they didn’t eat.* Peer relationships are going ok. The agency does well at providing counseling but could improve on communication among staff and
they feel that this dysregulates youth. Hygiene time for showers happens one youth at time. One youth expressed a desire to have parents visit in person, and
was told it doesn’t happen because of COVID precautions.** One youth reported a desire to have more outings, less daily “R&R” time, and more “stuff” to do
while the other youth reported having regular activities like playing video games, basketball, football, and Saturday outings.
*Per the program manager, the agency has not served products beyond dates listed on products and has been working on getting clear guidelines of expiration
dates, sell-by dates, use-by dates and best-by dates.
**The program manager and I discussed ways to accommodate in-person family visits with precautions to avoid the spread of COVID.
This coordinator had different conversations with two staff. One staff reported feeling more confident as the months have gone on since reopening, and the other
staff reported staff morale could improve, they feel managers have lack of dedicated time, and they would like the program’s census to increase. The program
manager reported having supportive upper management and shared challenges with staff turnover and competency.
Observations
The environment was welcoming, clean, and in good repair. The agency makes efforts to keep the concrete showers clean. Showers have rubber mats for
drainage and non-slippage. The kitchen was clean, and plenty of food was observed in the refrigerator, freezer and pantry. Staff were observed in the office and
in the milieu engaging with youth. One youth was doing their laundry, with staff supervision, and came out to communicate to another youth to take their laundry
out. The interaction was respectful.
Page 4 of 5
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report Rimrock Trails Treatment 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 to robin.m.duval@dhsoha.state.or.us.
Licensing Coordinator’s Signature: ________________________ Date: _1_1_/_2_/2_0_2_2__ _________
Manager Review: ______________________________________ Date: _1_1_-2_-_2_0_2_2_ _________
Page 5 of 5

program_type: (RC) Residential Care Programs

report_type: Unannounced

view_code: RC

licensee: Rimrock Trails Treatment Services

executive_director: Erica Fuller

visit_date: October 12, 2022

other_regulatory_agencies: Oregon Health Authority (OHA)

purpose:
Per OAR 413-215-0101 (1) (b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Findings Comments
2022 License Renewal Report 6/7/2022 - 6/8/2022
Further Action
Needed?
Medication 413-215-0551 (9) Written record of the disposal of medications is Yes✓No[ ] The medication disposal log was observed, and the form
maintained and includes: was properly filled out meeting rule requirements.
(a) description and amount
(b) name The above noted log was kept in the medication
(c) reason manager's office, which is a separate location from the
(d) method medication room where the bin of medications to be
(e) staff & witness signature disposed is located.
The agency did not have a medication disposal log at the time of this review, There was no tracking document within said bin,
however while on-site, the Medication Aide created a disposal log. The agency creating a risk of medication mismanagement or theft. I
shall ensure disposed medications are documented on the form with a staff and instructed the medication manager to utilize the disposal
witness signature. log form in the bin and begin tracking all medications
waiting for disposal. Repeat Finding.
It is recommended to dispose medications more
frequently to avoid any mismanagement or theft.
- This requirement is unmet and further
corrective action is needed.
Page 1 of 5
Medication 413-215-0551(10) Written record of the administration of Yes[ ] No✓ Electronic medication records were observed, and
medication includes: these requirements were met.
(e) medication disposed - No further corrective action needed.
(h) possible adverse reactions
(i) medication taken outside facility
The agency shall ensure (e), (h) and (i) are included on the record of the
medication administration record. This licensor recommended pre-set drop-down
fields such as refused (R), disposed (D), out of facility (OOF), etc. This is a repeat
finding from 2020.
Personnel Files 413-215-0061(1)(b) & (3)(b) reference checks completed and Yes[ ] No✓ Documentation of reference check requests (emails
documented. and calls requesting) is now included in the personnel
file as well as the completed reference checks.
The agency shall ensure reference checks are conducted, documented, and - No further corrective action needed.
retained in the personnel file.
Ongoing Training 413-215-0556(3) Staff providing direct care must maintain Yes[ ] No✓ Completed CPR/First Aid certifications were observed
current CPR/First Aid certification. meeting rule requirement.
- No further corrective action needed.
Records of completed CPR/First Aid certifications were missing. The agency
shall ensure current certifications are maintained in personnel files. This is a
repeat finding from 2018 and 2020.
Health Services 413-215-0546(2)(e) Documentation of age-appropriate Yes[ ] No✓ The agency has included age-appropriate instruction
instruction - pregnancy prevention, nutrition, prevention of HIV & AIDS, and topics in two recurring groups. The case managers'
prevention and treatment of sexually transmitted disease. running log identifies the date that each topic was
covered in a group session.
Documentation of age-appropriate instruction is unmet. The agency shall - No further corrective action needed.
ensure age-appropriate instruction occurs and is appropriately documented in
the child record.
Service Planning 413-215-0581(2)(e) (A)&(B) Service plan within 60 days Yes✓No[ ] Records were reviewed and child involvement was
(parent, guardian and child actively involved). Describes how child's issues will documented, however not the guardian/parent. The
be addressed, anticipated outcomes and reviewed by child and program manager stated the clinical staff had concerns
guardian/parent. involving guardians/parents due to potential privacy
concerns. Repeat Finding.
The service plan shall document involvement of the child and parent/guardian in
creation of the service plan as well as documented evidence that the service The service plan shall document involvement of the
plan was reviewed by the child and guardian/parent. child and parent/guardian in 1) creation of the service
plan, and 2) documented evidence that the service
plan was reviewed by the child and guardian/parent.
- This requirement is unmet and further
corrective action is needed.
Page 2 of 5
Case Management 413-215-0581(3)(b)-(d) discharge planning and Yes[ ] No✓ Records were reviewed and discharge planning and
instructions. instructions was readily identifiable and accessible in
the record.
The agency shall ensure the discharge planning is readily identifiable and
- No further corrective action needed.
accessible in the electronic record.
Financial Records 413-215-0581(4) Records contain date, amount, source, Yes✓No[ ] The newly implemented "Inventory for Safe" form was

interview_summary:
Two youth, ages 14, were individually interviewed and have been in the program approximately 21 days and 3 months, respectively. Both reported feeling safe,
gave personal examples of how this program is helping them, indicated staff and counselors are trusting, stated thar they have several phone and Zoom contacts
with parents weekly and indicated that food is good and plentiful. There was some food, i.e., apple sauce, protein shakes, that was served after the expiration
date that they didn't eat.* Peer relationships are going ok. The agency does well at providing counseling but could improve on communication among staff and
they feel that this dysregulates youth. Hygiene time for showers happens one youth at time. One youth expressed a desire to have parents visit in person, and
was told it doesn't happen because of COVID precautions.** One youth reported a desire to have more outings, less daily "R&R" time, and more "stuff" to do
while the other youth reported having regular activities like playing video games, basketball, football, and Saturday outings.
*Per the program manager, the agency has not served products beyond dates listed on products and has been working on getting clear guidelines of expiration
dates, sell-by dates, use-by dates and best-by dates.
**The program manager and I discussed ways to accommodate in-person family visits with precautions to avoid the spread of COVID.
This coordinator had different conversations with two staff. One staff reported feeling more confident as the months have gone on since reopening, and the other
staff reported staff morale could improve, they feel managers have lack of dedicated time, and they would like the program's census to increase. The program
manager reported having supportive upper management and shared challenges with staff turnover and competency.

previous_findings:
Repeat Findings Comments
2022 License Renewal Report 6/7/2022 - 6/8/2022
Further Action
Needed?
Medication 413-215-0551 (9) Written record of the disposal of medications is Yes✓No[ ] The medication disposal log was observed, and the form
maintained and includes: was properly filled out meeting rule requirements.
(a) description and amount
(b) name The above noted log was kept in the medication
(c) reason manager's office, which is a separate location from the
(d) method medication room where the bin of medications to be
(e) staff & witness signature disposed is located.
The agency did not have a medication disposal log at the time of this review, There was no tracking document within said bin,
however while on-site, the Medication Aide created a disposal log. The agency creating a risk of medication mismanagement or theft. I
shall ensure disposed medications are documented on the form with a staff and instructed the medication manager to utilize the disposal
witness signature. log form in the bin and begin tracking all medications
waiting for disposal. Repeat Finding.
It is recommended to dispose medications more
frequently to avoid any mismanagement or theft.
- This requirement is unmet and further
corrective action is needed.
Page 1 of 5
Medication 413-215-0551(10) Written record of the administration of Yes[ ] No✓ Electronic medication records were observed, and
medication includes: these requirements were met.
(e) medication disposed - No further corrective action needed.
(h) possible adverse reactions
(i) medication taken outside facility
The agency shall ensure (e), (h) and (i) are included on the record of the
medication administration record. This licensor recommended pre-set drop-down
fields such as refused (R), disposed (D), out of facility (OOF), etc. This is a repeat
finding from 2020.
Personnel Files 413-215-0061(1)(b) & (3)(b) reference checks completed and Yes[ ] No✓ Documentation of reference check requests (emails
documented. and calls requesting) is now included in the personnel
file as well as the completed reference checks.
The agency shall ensure reference checks are conducted, documented, and - No further corrective action needed.
retained in the personnel file.
Ongoing Training 413-215-0556(3) Staff providing direct care must maintain Yes[ ] No✓ Completed CPR/First Aid certifications were observed
current CPR/First Aid certification. meeting rule requirement.
- No further corrective action needed.
Records of completed CPR/First Aid certifications were missing. The agency
shall ensure current certifications are maintained in personnel files. This is a
repeat finding from 2018 and 2020.
Health Services 413-215-0546(2)(e) Documentation of age-appropriate Yes[ ] No✓ The agency has included age-appropriate instruction
instruction - pregnancy prevention, nutrition, prevention of HIV & AIDS, and topics in two recurring groups. The case managers'
prevention and treatment of sexually transmitted disease. running log identifies the date that each topic was
covered in a group session.
Documentation of age-appropriate instruction is unmet. The agency shall - No further corrective action needed.
ensure age-appropriate instruction occurs and is appropriately documented in
the child record.
Service Planning 413-215-0581(2)(e) (A)&(B) Service plan within 60 days Yes✓No[ ] Records were reviewed and child involvement was
(parent, guardian and child actively involved). Describes how child's issues will documented, however not the guardian/parent. The
be addressed, anticipated outcomes and reviewed by child and program manager stated the clinical staff had concerns
guardian/parent. involving guardians/parents due to potential privacy
concerns. Repeat Finding.
The service plan shall document involvement of the child and parent/guardian in
creation of the service plan as well as documented evidence that the service The service plan shall document involvement of the
plan was reviewed by the child and guardian/parent. child and parent/guardian in 1) creation of the service
plan, and 2) documented evidence that the service
plan was reviewed by the child and guardian/parent.
- This requirement is unmet and further
corrective action is needed.
Page 2 of 5
Case Management 413-215-0581(3)(b)-(d) discharge planning and Yes[ ] No✓ Records were reviewed and discharge planning and
instructions. instructions was readily identifiable and accessible in
the record.
The agency shall ensure the discharge planning is readily identifiable and
- No further corrective action needed.
accessible in the electronic record.
Financial Records 413-215-0581(4) Records contain date, amount, source, Yes✓No[ ] The newly implemented "Inventory for Safe" form was
purpose, signatures observed in a youth file. This form is used at the time of
intake; however, the agency shall have a form for
The agency shall create a form with all required elements to document any documenting any financial belongings during their stay
financial belongings (cash, coins, gift cards, etc.) of a child. This documentation in the program. Repeat Finding.
must be separate from a child's personnel possession record.
- This requirement is unmet and further
corrective action is needed.
Governance of the Agency 413-215-0021 Yes[ ] No✓ This violation has been corrected. No further action
needed.
(2)(f) Formally evaluate the exec. Director's performance annually
The agency shall submit the 2022 performance evaluation once finalized.
Supplemental Information Provided by CCA Yes[ ] No✓ This violation has been corrected. No further action
needed.
All required policies and procedures as identified in the "Umbrella Rules"
The agency shall update the Mandatory Abuse Reporting policy, specifically
regarding documentation of a report to authorities and including the additional
abuse types pertaining to child caring agencies. This licensor will provide
guidance with revisions.
Supplemental Information Provided by CCA Yes[ ] No✓ This violation has been corrected. No further action
needed.
All required policies and procedures as identified in "Residential Care Rules"
The agency shall update the Medication policies and procedures pursuant to
OAR 413-215-0551, specifically regarding disposal procedures and
documentation. This licensor will provide guidance with revisions.
Supplemental Information Provided by CCA Yes[ ] No✓ This violation has been corrected. No further action
needed.
SB710 Requirements: Policy and Procedures; notifications to guardian and
children in care.
OAR 413-215-0077(8)(e), (11)(e) and
OAR 413-215-0078(1)
The agency shall submit the policy and procedures, and notifications required to
clients and guardians; and shall ensure clients and guardians receive the
Page 3 of 5
notification at intake and twice yearly thereafter, and document having provided
it. This licensor will provide guidance.
Records and Documentation 413-215-0071 Yes[ ] No✓ This violation has been corrected. No further action
needed.
(3)&(4) Uniform in organization, readily identifiable and accessible, current, and
complete, containing all required info. No eraser tape or white out.
As noted above, some areas of records are incomplete.
New Findings from Site Visit
None


summary: Unannounced - 12 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Care
Licensee: Rimrock Trails Treatment Services
Executive Director: Erica Fuller
Program Director: Terri Brabo
Date of Unannounced: November 4, 2024
Licensing Coordinator: Robin DuVal
Other Regulatory or Accrediting Agencies: Oregon Health Authority (OHA)
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 Findings Comments
License Renewal Site Visit 05/14-15/2024 Further Action Needed
Installation and Use of Video Equipment Used to Monitor or Record Yes☐ No✓ This policy and procedure has been updated and
Children in Care 419-400-0145(1) If a child-caring agency installs video meets licensing requirements.
equipment to monitor or record a child in care, all employees, • The agency shall submit the final version in
volunteers, parents or guardians, and children in care must be informed PDF format.
about the intended use and locations of the equipment.
The agency shall update this policy to align with OAR 419-400-0145 and
submit for review.
Supplemental Information Provided by CCA Yes✓ No☐ The agency and licensor continue working
All required policies and procedures as identified in the “Umbrella Rules” collaboratively towards completion of updating policy
and procedure to meet rule requirement.
The agency shall update the Grievance policy and procedure pursuant
to OAR 419-400-0090(2) and submit for review.
Form Rev. 11/14/2023 P age 1 | 4
Once approved, the agency shall ensure all other documents
referencing this language are updated.
Residential Care Safety 419-470-0080(2) Written emergency plan that Yes☐ No✓ This policy and procedure has been updated and
includes: meets licensing requirements.
(a) Identifying the types of emergencies most likely to happen where the • The agency shall submit the final version in
residential care agency is located PDF format.
(b) Identifying a place to meet for each type of emergency identified
(c) Identifying an alternate shelter if necessary
(d) Ensuring access to necessary medications or medical equipment
(e) How to help each child in care recover after a disaster
The agency shall update emergency plan policies and procedures to
meet all requirements pursuant to OAR 419-470-0080(2) and submit for
review.
Residential Care Safety 419-470-0080(5)(a) Evacuation drill occurs Yes✓ No☐ Fire drill logs were missing for August 2024.
monthly under varying conditions, is retained 2 years and contains: • This is a repeat finding (May 2024).
(A) identify of person conducting drill
(B) date & time The repeat finding suggests that the processes in
(C) notification method place are insufficient. The agency shall provide
(D) staff participating Licensing with an Administrative Oversite Plan that
(E) # of children & staff evacuated details how ongoing compliance will occur, including
(F) special conditions simulated who will be directly responsible to ensure ongoing
(G) problems encountered compliance.
(H) time to complete
Several months of evacuation drills were not done, stating “no drill done
system being replaced”.
The agency shall ensure a monthly evacuation drill occurs. Alternative
notification methods can be a verbal command, bell, turning lights on/off,
etc.
New Employee Orientation – Umbrella Requirements (30 days) 419- Yes☐ No✓ Records were reviewed, and this requirement was
400-0120(4)(c) Suicide prevention and intervention met. There’s no further corrective action needed at
this time.
The agency shall ensure this training is completed within 30 days of hire.
New Employee Orientation – Umbrella Requirements (30 days) 419- Yes☐ No✓ Records were reviewed, and this requirement was
400-0120(4) met. There’s no further corrective action needed at
(e) & (5)(a) to (c) Mandatory reporting that includes: this time.
(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
The agency shall ensure this training is completed within 30 days of hire.
Form Rev. 11/14/2023 P age 2 | 4
New Employee Orientation Residential (Prior to working alone and Yes☐ No✓ Records were reviewed, and this requirement was
within 30 days) 419-470-0120(1)(d) Application of the reasonable and met. There’s no further corrective action needed at
prudent parent standard. this time.
The agency shall ensure this training is completed within 30 days of hire.
New Employee Orientation Residential (Prior to working alone and Yes☐ No✓ Records were reviewed, and this requirement was
within 30 days) 419-470-0120(1)(e) Training on the agency’s policy on met. There’s no further corrective action needed at
suicide prevention and suicide risk assessment tool. this time.
The agency shall ensure this training is completed within 30 days of hire.
Case Management 419-470-0170(3)(a) Services are documented, Yes☐ No✓ Records were reviewed, and this requirement was
progress toward achieving goals is tracked. met. There’s no further corrective action needed at
this time.
This information was not consistently documented. The agency shall
ensure this information is routinely documented.
Case Management 419-470-0170(3)(c) Discharge summary must Yes☐ No✓ Records were reviewed, and this requirement was
include: met. There’s no further corrective action needed at
(A)Current medications this time.
(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
Requirement (B) was not documented in the discharge summary. The
agency shall ensure information in (B) is documented within the
discharge summary.
Comment: Discharge planning information was not easily found within
client files, despite there being a discharge tab in the electronic system.
Records Relating to Restraint & Involuntary Seclusion Yes✓ No☐ The agency and licensor continue working
419-400-0190(1) Information provided to children in care relating to collaboratively towards completion of updating policy
Restraint & Involuntary Seclusion and procedure, and notification requirements, to
meet rule requirement.
The agency shall update documentation provided to children in care
specifically to meet this requirement.
Records and Documentation 419-400-0140(3)&(4) Uniform in Yes☐ No✓ Aside from missing the August fire drill, all other
organization, readily identifiable and accessible, current, and complete, areas are complete.
containing all required info. No eraser tape or white out.
Some areas of records are incomplete.
Form Rev. 11/14/2023 P age 3 | 4
New Findings from Site Visit Comments
None
Interview Summary
I met Terri Brabo, the new Residential Director, in person for the first time and she assisted with the electronic client record review. Brian Hodges, program
manager, accompanied me on the facility tour.
Two youth were individually interviewed, ages 17 and 16, with approximate stays of one month and both report this is their first program, and they feel safe here.
They described on-site recreation, activities, and outings. Food is ok, except it gets boring having cereal for breakfast every morning. Relationships with peers
and dorm room sharing is going ok, except some youth are messier than others. They have regular phone calls with family and have options for privacy, however
getting privacy is inconsistent among staff. One youth reports that the program is helping them with coping mechanisms and likes having peer support groups.
Some staff are trusting, including their therapist. They report that the agency could do better with ensuring consistent communication among staff across all
shifts, as well as staff demonstrating taking accountability when they mess up, essentially to model what is being taught to the youth.
Observations
The milieu areas were clean, tidy and in good repair. The kitchen was clean and food preparation was occurring along with the smell of freshly baked bread.
Adequate food supply was observed in food storage areas. Youth dorm rooms had varying levels of cleanliness/messiness typical for this age range, some
more tidy than others, some with extra piles of clothes on the floor; however, there were no odors or evidence of unhygienic conditions. Bathrooms were clean
and odor free.
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report Rimrock Trails Treatment 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 to Robin DuVal at Robin.M.DuVal@odhsoha.oregon.gov.
Licensing Coordinator’s Signature: ________________________ Date: _1_2_/_6_/2_0_2__4__________
Manager Review: ______________________________________ Date: __1_2_-_6_-2_0_2__4________
Form Rev. 11/14/2023 P age 4 | 4

facility_type: Residential Care

program_director: Terri Brabo

visit_date: November 4, 2024

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 Findings Comments
License Renewal Site Visit 05/14-15/2024 Further Action Needed
Installation and Use of Video Equipment Used to Monitor or Record Yes[ ] No✓ This policy and procedure has been updated and
Children in Care 419-400-0145(1) If a child-caring agency installs video meets licensing requirements.
equipment to monitor or record a child in care, all employees, - The agency shall submit the final version in
volunteers, parents or guardians, and children in care must be informed PDF format.
about the intended use and locations of the equipment.
The agency shall update this policy to align with OAR 419-400-0145 and
submit for review.
Supplemental Information Provided by CCA Yes✓ No[ ] The agency and licensor continue working
All required policies and procedures as identified in the "Umbrella Rules" collaboratively towards completion of updating policy
and procedure to meet rule requirement.
The agency shall update the Grievance policy and procedure pursuant
to OAR 419-400-0090(2) and submit for review.

Once approved, the agency shall ensure all other documents
referencing this language are updated.
Residential Care Safety 419-470-0080(2) Written emergency plan that Yes[ ] No✓ This policy and procedure has been updated and
includes: meets licensing requirements.
(a) Identifying the types of emergencies most likely to happen where the - The agency shall submit the final version in
residential care agency is located PDF format.
(b) Identifying a place to meet for each type of emergency identified
(c) Identifying an alternate shelter if necessary
(d) Ensuring access to necessary medications or medical equipment
(e) How to help each child in care recover after a disaster
The agency shall update emergency plan policies and procedures to
meet all requirements pursuant to OAR 419-470-0080(2) and submit for
review.
Residential Care Safety 419-470-0080(5)(a) Evacuation drill occurs Yes✓ No[ ] Fire drill logs were missing for August 2024.
monthly under varying conditions, is retained 2 years and contains: - This is a repeat finding (May 2024).
(A) identify of person conducting drill
(B) date & time The repeat finding suggests that the processes in
(C) notification method place are insufficient. The agency shall provide
(D) staff participating Licensing with an Administrative Oversite Plan that
(E) # of children & staff evacuated details how ongoing compliance will occur, including
(F) special conditions simulated who will be directly responsible to ensure ongoing
(G) problems encountered compliance.
(H) time to complete
Several months of evacuation drills were not done, stating "no drill done
system being replaced".
The agency shall ensure a monthly evacuation drill occurs. Alternative
notification methods can be a verbal command, bell, turning lights on/off,
etc.
New Employee Orientation - Umbrella Requirements (30 days) 419- Yes[ ] No✓ Records were reviewed, and this requirement was
400-0120(4)(c) Suicide prevention and intervention met. There's no further corrective action needed at
this time.
The agency shall ensure this training is completed within 30 days of hire.
New Employee Orientation - Umbrella Requirements (30 days) 419- Yes[ ] No✓ Records were reviewed, and this requirement was
400-0120(4) met. There's no further corrective action needed at
(e) & (5)(a) to (c) Mandatory reporting that includes: this time.
(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
The agency shall ensure this training is completed within 30 days of hire.

New Employee Orientation Residential (Prior to working alone and Yes[ ] No✓ Records were reviewed, and this requirement was
within 30 days) 419-470-0120(1)(d) Application of the reasonable and met. There's no further corrective action needed at
prudent parent standard. this time.
The agency shall ensure this training is completed within 30 days of hire.
New Employee Orientation Residential (Prior to working alone and Yes[ ] No✓ Records were reviewed, and this requirement was
within 30 days) 419-470-0120(1)(e) Training on the agency's policy on met. There's no further corrective action needed at
suicide prevention and suicide risk assessment tool. this time.
The agency shall ensure this training is completed within 30 days of hire.
Case Management 419-470-0170(3)(a) Services are documented, Yes[ ] No✓ Records were reviewed, and this requirement was
progress toward achieving goals is tracked. met. There's no further corrective action needed at
this time.
This information was not consistently documented. The agency shall
ensure this information is routinely documented.
Case Management 419-470-0170(3)(c) Discharge summary must Yes[ ] No✓ Records were reviewed, and this requirement was
include: met. There's no further corrective action needed at
(A)Current medications this time.
(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
Requirement (B) was not documented in the discharge summary. The
agency shall ensure information in (B) is documented within the
discharge summary.
Comment: Discharge planning information was not easily found within
client files, despite there being a discharge tab in the electronic system.
Records Relating to Restraint & Involuntary Seclusion Yes✓ No[ ] The agency and licensor continue working
419-400-0190(1) Information provided to children in care relating to collaboratively towards completion of updating policy
Restraint & Involuntary Seclusion and procedure, and notification requirements, to
meet rule requirement.
The agency shall update documentation provided to children in care
specifically to meet this requirement.
Records and Documentation 419-400-0140(3)&(4) Uniform in Yes[ ] No✓ Aside from missing the August fire drill, all other
organization, readily identifiable and accessible, current, and complete, areas are complete.
containing all required info. No eraser tape or white out.
Some areas of records are incomplete.

New Findings from Site Visit Comments
None
Interview Summary
I met Terri Brabo, the new Residential Director, in person for the first time and she assisted with the electronic client record review. Brian Hodges, program
manager, accompanied me on the facility tour.
Two youth were individually interviewed, ages 17 and 16, with approximate stays of one month and both report this is their first program, and they feel safe here.
They described on-site recreation, activities, and outings. Food is ok, except it gets boring having cereal for breakfast every morning. Relationships with peers
and dorm room sharing is going ok, except some youth are messier than others. They have regular phone calls with family and have options for privacy, however
getting privacy is inconsistent among staff. One youth reports that the program is helping them with coping mechanisms and likes having peer support groups.
Some staff are trusting, including their therapist. They report that the agency could do better with ensuring consistent communication among staff across all
shifts, as well as staff demonstrating taking accountability when they mess up, essentially to model what is being taught to the youth.
Observations
The milieu areas were clean, tidy and in good repair. The kitchen was clean and food preparation was occurring along with the smell of freshly baked bread.
Adequate food supply was observed in food storage areas. Youth dorm rooms had varying levels of cleanliness/messiness typical for this age range, some
more tidy than others, some with extra piles of clothes on the floor; however, there were no odors or evidence of unhygienic conditions. Bathrooms were clean
and odor free.

excerpt:
419-400-0140(3)&(4) Uniform in Yes[ ] No✓ Aside from missing the August fire drill, all other
organization, readily identifiable and accessible, current, and complete, areas are complete.
containing all required info. No eraser tape or white out.
Some areas of records are incomplete.
New Findings from Site Visit Comments
None
None


facility_name: St. Mary's Home For Boys

summary: Unannounced - 3 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: St. Mary’s Home for Boys
Executive Director: Francis Maher
Assistant Director: Jeff Pinelli
Date of Unannounced: December 8, 2021
Licensing Coordinator: Robin DuVal
Other Regulatory or Accrediting Agencies: Oregon Department of Human Services (ODHS) Child Welfare Treatment Services and Oregon
Youth Authority (OYA).
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 Findings Comments
License Renewal 07-31-2021 Further Action Needed
413-215-0576(1)(d) Consents: Restrict contact with persons Yes☐ No
outside of the agency. “The agency shall ensure consent (d) is
obtained from the guardian at intake and clearly documented.” Two youth files were reviewed and these
413-215-0576(2) Disclosures: Parent/guardian has Yes☐ No consents and disclosures, along with the specific
acknowledged in writing: list of visitors, were clearly documented and
(b) Child specific visitors signed by guardian. No further corrective action
(c) Visitation resources are pre-approved needed.
“The agency shall ensure authorizations (b) and (c) are obtained
from the guardian at intake and clearly documented.”
New Findings from Site Visit Comments
413-215-0551(10) Written record of the The agency shall ensure the written record of the medication administration are filled out accurately
administration of medication. without blanks. The medication administration records (MARs) in each cottage had varying levels of
blanks. Staff were asked about the blanks and some were unaware of the legend noted on the MAR
for proper documentation.
1 of 2
Interview Summary
Youth N. has been in the program for approximately 6 months. Food is delicious and gets plenty. Has regular unrestricted contact with family. No
issues with medication administration. Favorite thing is being out in the community. Least favorite is staff inconsistency with punishment. Some
youth get a writing assignment for cursing, with some others don’t. The therapist is liked and trusting. Feels staff protect youth when other youth
experience challenges. Has observed a couple of physical restraints and thinks it’s done in a safe way. Doesn’t hear other youth talk or complain
about restraints.
Youth E. is 18 years old and has been in the program for approximately two years. Feels safe here. The program has really helped with anger,
coping skills and learning empathy. Enjoys playing basketball and this is one of the coping skills utilized. Least favorite experience at the program
is being in the isolation room, which occurred seldom, and last occurrence was over a year ago. Food is pretty good, and alternatives are offered.
Staff are trusting. The program does well at helping people. Has regular unrestricted contact with family and other involved parties. Peers in living
unit are supportive and help each other.
Staff M. has worked here approximately 6 months and really likes how the program runs. Says they do well at addressing individual needs of the
youth and are inclusive of nonbinary people. Staffing retention is challenging, and he realizes it’s a statewide issue across all business types. CPI
training occurred within the first week of training, and the agency has had ongoing training and review in restraints.
Staff D. has been involved in one physical restraint since the implementation of SB710 and feels the staff did a really good job and are grasping
the revised method. The staff review following the restraint was positive and supportive.
Observations
The four living units were observed and were clean, welcoming, and in good repair. Ford Cottage had a few bedrooms that were messy, floors
covered with various items, mattress on floor, and mild odor. Staff said a few youth have been struggling, and the program has been very involved
with each youth and their specific needs.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report, St. Mary’s Home for Boys 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 are
to be emailed directly to Robin DuVal, ROBIN.M.DuVal@dhsoha.state.or.us.
Licensing Coordinator’s Signature: ________________________ Date: _____1_2_/_1_5_/_2_0__2_1_ ___
Manager Review: ______________________________________ Date: _1_2_-_1_5_-_2_0_2_1_ _______
2 of 2

agency_name: St. Mary's Home For Boys (SMHB)

program_name: St. Mary's Home For Boys

licensee: St. Mary's Home for Boys

executive_director: Francis Maher

visit_date: December 8, 2021

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 Findings Comments
License Renewal 07-31-2021 Further Action Needed
413-215-0576(1)(d) Consents: Restrict contact with persons Yes[ ] No
outside of the agency. "The agency shall ensure consent (d) is
obtained from the guardian at intake and clearly documented." Two youth files were reviewed and these
413-215-0576(2) Disclosures: Parent/guardian has Yes[ ] No consents and disclosures, along with the specific
acknowledged in writing: list of visitors, were clearly documented and
(b) Child specific visitors signed by guardian. No further corrective action
(c) Visitation resources are pre-approved needed.
"The agency shall ensure authorizations (b) and (c) are obtained
from the guardian at intake and clearly documented."
New Findings from Site Visit Comments
413-215-0551(10) Written record of the The agency shall ensure the written record of the medication administration are filled out accurately
administration of medication. without blanks. The medication administration records (MARs) in each cottage had varying levels of
blanks. Staff were asked about the blanks and some were unaware of the legend noted on the MAR
for proper documentation.
1 of 2
Interview Summary
Youth N. has been in the program for approximately 6 months. Food is delicious and gets plenty. Has regular unrestricted contact with family. No
issues with medication administration. Favorite thing is being out in the community. Least favorite is staff inconsistency with punishment. Some
youth get a writing assignment for cursing, with some others don't. The therapist is liked and trusting. Feels staff protect youth when other youth
experience challenges. Has observed a couple of physical restraints and thinks it's done in a safe way. Doesn't hear other youth talk or complain
about restraints.
Youth E. is 18 years old and has been in the program for approximately two years. Feels safe here. The program has really helped with anger,
coping skills and learning empathy. Enjoys playing basketball and this is one of the coping skills utilized. Least favorite experience at the program
is being in the isolation room, which occurred seldom, and last occurrence was over a year ago. Food is pretty good, and alternatives are offered.
Staff are trusting. The program does well at helping people. Has regular unrestricted contact with family and other involved parties. Peers in living
unit are supportive and help each other.
Staff M. has worked here approximately 6 months and really likes how the program runs. Says they do well at addressing individual needs of the
youth and are inclusive of nonbinary people. Staffing retention is challenging, and he realizes it's a statewide issue across all business types. CPI
training occurred within the first week of training, and the agency has had ongoing training and review in restraints.
Staff D. has been involved in one physical restraint since the implementation of SB710 and feels the staff did a really good job and are grasping
the revised method. The staff review following the restraint was positive and supportive.
Observations
The four living units were observed and were clean, welcoming, and in good repair. Ford Cottage had a few bedrooms that were messy, floors
covered with various items, mattress on floor, and mild odor. Staff said a few youth have been struggling, and the program has been very involved
with each youth and their specific needs.