state: OR

facility_name: Morrison Child and Family Services Date of site visit: November 4th - 7th, 2024

summary: License Renewals - 25 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Licensee: Morrison Family Services Date of site visit: March 29 through April 5, 2021
Executive Director: Drew Henrie-McWilliams Licensing Coordinator: Holly Ivey, Tom Heidt, and Irvin Minten
Program Compliance: The program is or will be compliant with OAR 413-215-0001 through 0131 Licensing Umbrella Rules, OAR 413-215-0301
through 0396 Licensing Foster Care Agencies, OAR 413-215-0501 through 0586 Licensing Residential Care and OAR 413-215-0801 through 0856
Licensing Day Treatment.
Personnel records were reviewed and compliance with required background checks was documented for employees in all programs.
Agency Description(s):
Morrison Child and Family Services was founded in 1947, by Carl V. Morrison, who was a psychologist in Portland. It has grown to be a large
organization, with a projected annual budget of around 30 million, and they employ approximately 405 staff. Morrison Family Services served 7,935
children and families in 2019-2020. Morrison has programs that are licensed by DHS Licensing and outpatient programs that are not.
Individual Program Description(s):
Planned and Crisis Respite- Provides planned or emergency short-term overnight respite services for children 3-17 years old. Respite providers
are certified Therapeutic Foster Parents through Morrison. The providers have been screened and specially trained to work with children and youth
who have a history of mental illness and may have been impacted by trauma. Respite homes provide a safe, supportive and structured
environment in which youth can take advantage of new opportunities. The average length of stay in 2020 was 2 days and the service is primarily
utilized on weekends. At the Licensing Review it was reported there were 15 certified foster homes, with a capacity to serve 34 children.
Therapeutic Foster Care-
Morrison’s Therapeutic Foster Care (TFC) program provides a safe and nurturing environment with care provided by specially screened parents
who are trained to work with children and youth impacted by trauma. TFC children and youth are 3-17 years old living in the Portland-Metropolitan
area and have been referred by their Child Welfare Caseworker for Therapeutic Foster Care because of clinical and behavioral issues that require
specialized care. Morrison’s TFC program is contracted to provide care for up to 12 children. Often youth participating in TFC have experienced
multiple attachment disruptions and have suffered neglect as well as severe physical, sexual and emotional trauma. As a result, they can
experience mental health and behavioral issues that make it difficult for them to cope with daily routines and relationships. The average length of
stay in 2020 was 452 days. At the Licensing Review it was reported there were 4 certified foster homes, with a capacity of to serve 7 children.
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 170823)
Breakthrough Day Treatment – Breakthrough is an innovative day treatment program that combines substance use disorder treatment, skills
training, psychiatric services and alternative education. Day treatment is combined with proctor care to create 24 hour, 7 days/week therapeutic
environments for youth served. The day treatment program is open 8:45am to 4 p.m. Monday-Friday and proctor homes provide care, support and
supervision during evenings and weekends. Day treatment programming includes a variety of individual, group and family treatment and an on-site
accredited classroom provided by Portland Public Schools. The primary method of treatment is group counseling aimed at helping youth with social
behaviors, substance use problems and other key issues, such as anger management, family relationships and decision making. Health care
monitoring and follow-up services are also provided. The school and treatment components are interwoven throughout the program day and
include recreational activities and a meal service for youth placed in the program. The program utilizes Cognitive Behavioral Therapy, Motivational
Interviewing and a variety of other evidence-based practices that have proven successful for treatment of delinquency and substance abuse. Youth
receive an intensive program modeled on positive peer culture and responsibility to others. Youth referred to the Program are 12-17 years old, have
substance use problems, are usually involved with the juvenile justice system and have often been unsuccessful in other treatment settings.
Referrals for day treatment are taken from multiple sources such as DHS, schools and parents or family members. The combined day treatment
and proctor home program only accepts referrals from the Oregon Youth Authority.
Breakthrough Foster Care – Proctor parents are recruited and trained by Breakthrough Staff and are certified through the Oregon Youth Authority.
Breakthrough staff provide intensive training, support, and coaching to assist proctor parents in responding to key social, emotional, and behavioral
concerns that youth have. Proctor parents receive monthly home visits, attend weekly training, and support groups, and receive daily
communication about the needs and behavior of youth in care. Proctor parents also receive individualized coaching when they request additional
support, when youth needs increase or change significantly, and when staff assess that increased supervision would be beneficial. Breakthrough
proctor parents are expected to develop therapeutic relationships with youth, provide safe, healthy home environments, and support 12-Step
Programs and recovery activities. At the time of the Licensing Review it was reported there were 4 certified homes with a capacity of 4 beds. The
average length of stay in 2020 was 104 days.
Counterpoint Day Treatment -This program was founded in 1983. The Counterpoint Day Treatment and Proctor Care Program is a
comprehensive program that combines mental health and sexual offending treatment approaches with an accredited school program and proctor
care. The day program is open 8:45 am to 4:00 p.m. Monday-Friday and serves adolescent boys 12 to 17 years old that have sexual behavior
difficulties. Proctor homes provide care, support and supervision evenings and weekends for youth in OYA custody. Youth can be referred through
various sources: families, DHS, school, although most are referred by the Oregon Youth Authority staff. Treatment services occur throughout the
day and include peer group meetings, offender accountability groups, abuse survivor/personal history groups, alcohol and drug education groups,
alcohol and drug treatment groups and behavioral skills groups. Group skills training also includes sex education, anger management,
assertiveness training and healthy relationships. Youth have access to individual and family counseling, medical care, case management and
psychiatric services. A full range of adolescent substance use treatment and recovery services are provided when needed. This program focuses
on teaching positive, age-appropriate social skills while helping clients to resolve personal issues and cope with earlier trauma. Research indicates
that early intervention with adolescents can eliminate future sexual offenses as well as significantly decrease the likelihood of social, emotional and
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developmental problems from developing later in their lives. The school day is provided by Portland Public School teaching staff. Cognitive-
behavioral treatment strategies and interventions are used throughout the program.
Counterpoint Foster Care – Youth live in proctor care homes specifically recruited and supported by Morrison to provide a therapeutic home
environment. Proctor parents are certified through the Oregon Youth Authority. Proctor parents receive training, supervision, and support by
Morrison Staff. Proctor parents are highly involved in care planning and receive information daily from day treatment staff about youth progress and
behavior. Counterpoint staff provide monthly home visits and home inspections to provide feedback and support for proctor parents. Proctor
parents also receive individualized coaching when they request additional support, when youth needs increase or change significantly and when
staff assess that increased supervision would be beneficial. For safety and therapeutic reasons, no young children are placed in these homes. At
the Licensing Review it was reported there were 3 certified homes with a capacity to serve 9 children. The average length of stay for youth in care
during 2020 was 374 days.
Downtown Shelter – The Downtown Shelter is a 50-bed youth shelter located in downtown Portland that serves immigrant youth, 13-17 years old.
Both males and females are served but housed in separate areas of the facility. The Program opened July 2014. It provides temporary housing in
a supervised living environment, 6 hours of education per day and case management services designed to support the re-unification process.
Referrals are made to community resources for outpatient medical, dental and mental health services. Supportive counseling services are also
provided by Downtown Shelter clinicians when needed. The primary goal of the Program is for children to be placed with family members or an
identified sponsor. Services are designed to achieve this goal. The Downtown Shelter program provides residential services in partnership with the
US Department of Health and Human Services, Administration for Children and Families, Office of Refugee and Resettlement (ORR). All services
are planned and coordinated with ORR Federal Field Specialists acting as legal guardians. Youth are referred to the Shelter based upon an
assessment of their developmental and behavioral needs that indicates that they can function safely and successfully in an open, less restrictive
environment. Individual service needs and level of care is reviewed frequently (every 30 days) with the ORR Federal Field Specialist. In this model
influenced by child welfare practices, Morrison does not make initial placement, transfer or discharge decisions but acts as a care provider and
advocate for the youth. The population served is primarily immigrant youth from Central and South America who have entered the United States
without parents or legal guardians and without a legal immigration status. The youth typically speak Spanish or indigenous languages spoken in
their home countries. The average length of stay in 2020 was 46 days.
Long Term Group Home-The Long-Term Group Home is a residential program serving immigrant youth, 13-17 years old. It is co-located with the
Morrison Downtown Shelter Program but has separate physical space and staffing. The Program opened in April 2017. The Long-Term Group
Home program provides residential care, health care follow-up, socialization/recreation, life skills training and development, access to legal
services, case management services and mental health counseling, if needed. Youth placed in the program attend Lincoln High School during the
day and return to the Program after school and extra-curricular activities are completed. All services are coordinated closely with ORR Federal
Field Specialists who act as legal guardians. In this model influenced by child welfare practices, Morrison does not make placement or discharge
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decisions, but acts as a care provider and advocate for youth served. Immigrant youth served within the Long-term Group Home program do not
typically have serious behavioral or developmental concerns. They require a long-term placement, usually 6-9 months, because there is not an
identified family member or adult sponsor to act as a legal guardian in the US. Consequently, programmatic and system goals are to assist youth in
understanding and adjusting to their legal status and prepare for independent living. Family or sponsor re-unification remains a goal if it is possible
to achieve. Services provided are community-based, supportive, and “as-needed”. Youth attend a public high school and participate in extra-
curricular high school activities without direct, face-to-face supervision from program staff. They receive less frequent case management services
and utilization of supportive counseling services is not required. Additional criteria for placement within the Long-term Group Home include: being
under the age of 17.5 years at the time of placement and potential eligibility for “immigration” or “legal” relief. The population served are primarily
youth from Central or South America who speak Spanish and indigenous languages spoken in their home countries. They have entered the United
States without a parent or legal guardian and without legal immigration status. The average length of stay in 2020 was 175 days
Paso Residential Care – The PASO program is a comprehensive 16-bed residential program serving 13-17-year-old immigrant youth with
significant behavioral needs. The Program opened in December 2009 and is located within the Morrison Mt. Scott Facility. It provides
comprehensive, supervised care, two hours per day of structured social and recreational activities, 6 hours of education, case management
services that emphasize reunification with family members or an adult sponsor, supportive counseling services, referrals to community-based
medical and mental health services and health care follow-up. For significant mental health concerns youth are referred to outpatient psychiatric
and/or psychological practitioners or emergency mental health services. The Program provides short-term residential care in a safe, closely
supervised, yet supportive living environment. Intensive case management services are a hallmark of the program, ensuring that youth are
released timely and safely from federal custody to parents, family members or adult sponsors who can care for the adolescent’s physical and
mental well-being. Due to the need to provide highly individualized care and intensive supervision, the Program has enhanced its staffing to include
a behavioral support specialist and a residential security specialist. The PASO program provides residential care in close partnership with the US
Department of Health and Human Services, Administration for Children and Families, Office of Refugee and Resettlement (ORR). All services
provided are planned and coordinated with ORR Federal Field Specialists who act as legal guardians for the minor children placed with Morrison.
They assess individual needs, level of care and supervision required, and then refer youth to PASO when they meet criteria for the ORR Staff
Secure level of care. Youth placed at PASO (designated as an ORR Staff Secure Program) have significant histories of behavioral difficulties
including anger outbursts, runaway behaviors and minor criminal violations, often combined with trauma and mental health needs. The population
served are primarily Spanish-speaking immigrant youth from Central and South America who have entered the United States without a parent or
legal guardian and without a legal immigration status. The primary goal of the Morrison program is placement of youth with their parents, family
members or sponsors as quickly and safely as possible and to assure a smooth transition of care. While placed at Morrison, additional goals
include assuring the safety and well-being of youth in our care and responding to their individual health, educational and developmental needs. The
average length of stay in 2020 was 47 days.
SAGE Residential – The Support, Achieve, Grow, and Empower (SAGE) Program serves Commercially Sexually Exploited Children (CSEC) who
have been identified as needing intensive services to prevent future victimization. The secure residential setting allows staff to build a relationship
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with each youth while engaging them in services. The foundation of the CSEC program is the Sanctuary Model, and the milieu utilizes Collaborative
Problem Solving. SAGE serves female identifying youth, ages 11 to 16.5, who are residents of the state of Oregon and have experienced
commercial sexual exploitation. The program is designed to last 11 to 14 months. It includes a full range of mental health treatment (individual,
group, family, psychiatric), substance abuse treatment, milieu therapy, on site education, medical case management services and education and
treatment specific to commercial sexual exploitation and sex trafficking. Portland Public Schools provides an on-site school. Their contract with
Oregon Health Authority is for 12 youth, ages 11-16.5, but the program has the capacity to serve 26 youth ages 10-17. The average length of stay
in 2020 was 268 days.
Program type and services: Residential, Foster Care, and Day Treatment Services
Number of proctor foster parents and program capacity: The number of proctor foster parents and program capacity was identified by program
managers.
Planned Crisis Respite Foster Care: 15 certified foster homes, capacity 34
Foster Care Program: 4 certified foster homes, capacity- 7
Breakthrough: 4 certified foster homes, capacity- 4
Counterpoint: 3 certified foster homes, capacity- 9
Average length of stay: The average length of stay was identified by program managers.
Planned Crisis Respite Foster Care: (Primarily this service is only utilized on weekends)
 2019- 2-3 days
 2020- 2 days
Foster Care Program:
 2019- 700 days
 2020- 452 days
Breakthrough:
 2019- 164 days
 2020- 104 days
Counterpoint:
 2019- 459 days
 2020 374 days
Paso:
 2019- 76 days
 2020- 47 days
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SAGE:
 2019 305 days
 2020 268 days
Residential Care Program Update-Long Term Group Home:
 2019- 196 days
 2020- 175 days
Residential Care Program Update-Shelter:
 2019- 61 days
 2020- 46 days
Average daily population served: The average daily population was identified by program managers.
Planned Crisis Respite Foster Care:
 2019- 52 children
 2020- 39 children
Foster Care Program:
 2019-5 children
 2020- 4 children
Breakthrough:
 2019- 4 children
 2020-1 children
Counterpoint:
 2019-9 children
 2020- 6 children
Paso:
 2019- 9 children
 2020- 2 children
SAGE:
 2019-11 children
 2020- 9 children
Residential Care Program Update-Long Term Group Home:
 2019-11 children
 2020-26 children
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Residential Care Program Update-Shelter:
 2019-38 children
 2020- 16 children
Number of children served annually: Number of children served was identified by program managers.
Planned Crisis Respite Foster Care:
 2019- 191 children
 2020-143 children
Foster Care Program:
 2019-8 children
 2020-11 children
Breakthrough:
 2019-19 children
 2020-17 children
Counterpoint:
 2019- 16 children
 2020- 19 children
Paso:
 2019-52 children
 2020- 19 children
SAGE:
 2019-30 children
 2020- 30 children
Residential Care Program Update-Long Term Group Home:
 2019-28 children
 2020- 26 children
Residential Care Program Update-Shelter:
 2019- 276 children
 2020-154 children
Use of seclusion or restraint: Morrison programs prohibit seclusion. Staff at the following programs are trained in Non-violent Crisis Intervention
(NCI) as restraints are allowed in emergency situations. Paso, The Downtown Long-Term Group Home and Shelter, The Foster Care Programs to
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include foster parents. SAGE Staff are trained in the Mandt Intervention System. Counterpoint and Breakthrough Day Treatment are “hands off”
programs. The staff are trained in NCI’s non-physical interventions and de-escalation techniques.
Interviews, Observations: At the Licensing Review nine staff members, two foster parents and eleven children were interviewed. The following
information was gained during the interviews with the children:
 Many children reported appreciating the staff.
 The children all reported being able to talk to people on their approved contact list.
 All the children reported being provided enough food to eat, to include receiving daily snacks.
 The children all reported their hygiene needs were being met by the program.
 All the children reported feeling safe at the programs where they were residing, to include foster homes.
There were no concerns that were identified during the interviews with staff, foster parents or children. While conducting the onsite inspection at the
programs children and staff were observed. The children that were observed appeared to be at ease and comfortable while residing in the
programs. The facilities were observed to be well maintained, with minimal repair needs.
Program Strengths:
The following strengths were identified by Licensing Staff:
 Files were consistent and well organized across all programs. Files included multiple tabs that clearly marked each section.
 Across all programs it appeared staff were committed to the care of the children served.
 Staff are well qualified for their positions.
 The children in the program are receiving evidence-based treatment to meet their complex needs.
Individual program strengths identified by program managers.
 Planned Crisis Respite Foster Care:
o “A significant program strength is the willingness of existing respite providers to provide services in their homes during the COVID-19
pandemic. They have adapted very flexibly to following extensive infection control guidelines.
o Another strength of the program lies in the quality of the respite staff. They demonstrate keen abilities in coordinating care and services
and providing extensive after-hours supports. Both respite providers and staff are committed to supporting children and youth and
promoting their healthy development by preventing unnecessary disruptions in the relationships that they have with others.”
 Foster Care Program:
o “Therapeutic Foster Care (TFC) provides a safe and nurturing care-giving environment provided by parents who are specially trained and
screened to work with children impacted by trauma. The program provides intensive case management, skills training and 24-hour crisis
response to support children and youth in meeting individualized treatment goals and placement stabilization.
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o The TFC Program increased the number of youth served during 2019 from an average of 4 youth to an average of 8 youth. One youth is
stepping over to DHS care and remaining in their long-term placement and two youth have successfully reunified with their biological
parent.
o The program has strong collaboration with Morrison’s Planned and Crisis Respite program to provide much needed relief for the TFC
families.
o Foster home recruitment and retention continues to prove challenging during the COVID-19 pandemic. However, efforts with the Foster
Plus Collaborative and Morrison’s recent implementation of an advertising campaign has improved exposure and increased the pool of
interested resource families. TFC has hired new case managers and a Program Supervisor to sustain the program.
o TFC has begun implementation of the Attachment, Regulation and Competency (ARC) model with clients and the ARC Reflections
curriculum for foster parents.”
 Breakthrough and Counterpoint:
o “Many Counterpoint Day Treatment program youth make significant academic progress while in the Program, gaining high school
credits and advancing grade levels more quickly than in the past.
o Program youth have a very low juvenile justice recidivism rate.
o Program youth have opportunities to engage in cultural and recreational activities that they may not have had before.
o The Counterpoint Day Treatment and Proctor Care Program has a stable group of experienced proctor homes, ranging from 5-10
years longevity with Counterpoint.”
 Paso:
o “According to the Office of Refugee and Resettlement, the Morrison PASO program is a Staff Secure program. It is one of only 5
Staff Secure programs in the nation and has been operating for 10 years with many experienced staff.
o PASO has adapted programmatically to respond to the increasing mental health needs of the youth served in the program. PASO
has developed a wide variety of mental health services, recreational services and a robust calendar of engaging activities for the
youth served.
o The program has benefitted from many facility improvements and renovations this year and has a fresh, new, inviting and youth-
friendly environment and atmosphere.
o PASO staff are a strength of the program. They are currently participating in Dialectical Behavioral Therapy (DBT) training with the
goal of becoming certified in this evidence-based approach. They use a wide range of therapeutic interventions to meet the
individual needs of youth who come into the PASO program. In addition, most staff are bilingual/bi-cultural and all have a strong
passion for serving the youth at PASO.
o Youth report satisfaction with the program, and that they feel supported by the program.”
 SAGE:
o “SAGE (Strength, Achievement, Growth, and Empowerment) is trauma informed and strengths based. Treatment is youth centered and
youth driven.
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o SAGE Staff are provided ongoing training opportunities specific to work with trauma survivors. The program is able to address multiple
client needs simultaneously, including safety, which would be difficult to do in a less restrictive setting.
o The program offers individualized educational opportunities with credit recovery options to re-engage youth in education. Individual art
and music lessons are offered per youth request. SAGE offers vocational training opportunities for youth who may be entering the
workforce upon discharge, and we collaborate with community partners to create effective systems of support for youth while they’re in
the program and when they return to the community.”
 Residential Care Program Update-Long Term Group Home:
o ‘Youth report that they are satisfied with services and feel supported by the program.
o The program has a successful partnership with Lincoln High School, where the youth attend school. Youth have the support of
program staff to meet academic and other school-related goals.
o Staff bring unique creativity to the task of decorating and outfitting the program facility; the environment creates an atmosphere of
support and comfort for the youth.
o Individualized skill building, independent living skills training and acculturation activities are provided for the youth. The youth have
access to a wealth of local resources for educational and recreational opportunities.
o Collaborative Problem Solving is utilized to respond to youth behavior.
o The Program has benefitted from experienced leadership (Program Director, Assistant Program Director) and case management
staff.
o Youth have successfully entered the State of Oregon foster care system from the program.
o The program implemented the Child and Youth Care Certification Model, with the goal of increasing staff skills, competency and
retention. The Long-Term Group Home implemented a child and youth care worker certification program and have encouraged
Milieu Counselors to become certified.
o The Child and Youth Care Certification Board Model (CYCCB). The CYCCB model provides an assessment and training process
that leads to national certification. Staff competencies are organized across five domains: professionalism, cultural and human
diversity, applied human development, relationships and communication and developmental practice methods.”
 Residential Care Program Update-Shelter:
o “Youth served reported overall satisfaction with the program and that they received support from the program during their stay.
o Increased staff training has occurred at the Downtown Shelter since the last licensing renewal. Training has included the following:
Child and Youth Care Certification Board (CCYCB) recommended trainings for youth care workers, Nonviolent Crisis Intervention,
Columbia Suicide Severity Rating Scale Screening, Collaborative Problem Solving (CPS) and the trauma-informed Sanctuary Model.
Milieu Counselors are working towards Child and Youth Care Worker certification. Sanctuary Model training has helped reduce staff
burnout and increase morale. Creating opportunities for staff to participate in brief in-service trainings, “Sanctuary Snacks”, allows
time for reflection and team building. With the goals of increasing professional competency and skills and retaining direct service
staff, the Downtown Shelter program began the implementation of the Child and Youth Care Certification Board (CYCCB) model
during the past year. The CYCCB model provides an assessment and training process based upon five domains of study and
practice: professionalism, cultural and human diversity, applied human development, relationships and communication, and
developmental practice methods.
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o Staff have been cross-trained in different areas allowing for back-up coverage and consistent program operations when there is a
fast-paced work environment and staff turnover.
o The Downtown Shelter has created a welcoming environment for youth by integrating more culturally appropriate resources in the
school program, recreational activities, food service, community groups, and mental health referrals. Recreational spaces for youth
such as the second-floor gym and activity rooms have allowed youth to find a safe and healthy method for calming and self-soothing
activities. Youth have benefited from recreational activities such as yoga, soccer coaching, educational outings, gardening classes,
and talent shows.
o Only one Downtown Shelter youth was recommended for a higher level of care during the past year.”
Program Challenges: Individual challenges identified by program managers.
 Planned Crisis Respite Foster Care:
o “Morrison respite services faced multiple challenges during the past two years – difficulties in engaging, recruiting, and maintaining
respite providers during the COVID-19 pandemic and financial instability when specialized funding ended. Morrison made the difficult
decision to close our Mid-Valley Respite program when pilot funding ended December 31, 2019. The number of homes that had
been recruited, and the volume of respite care provided, did not support the cost of the program.
o An on-going challenge is having enough respite beds to meet the needs of the populations and communities served.”
 Foster Care Program:
o “TFC has experienced a high rate of changes as a program over several years, including closure of the Knott site, program re-
location and significant leadership changes. These transitions have led to difficulty in stabilizing the TFC program, including a high
turnover rate among staff into the 2018-2019 fiscal year. However, significant efforts are underway to stabilize the program including
hiring a Division Director, filling vacant Case Manager positions and hiring a Program Supervisor. Plans are underway to hire a
therapist for the team as well.
o Recruitment of skilled foster parents has remained a challenge over the last few years. Changes in reporting requirements, negative
press about foster care and fears about allegations have led to a difficulty maintaining a pool of qualified foster parents. Morrison
continues to participate in Foster Plus to help with recruitment efforts, and significant improvements to our program are underway. In
addition, increases in daily rates to support appropriate staffing, recruitment efforts and increased payments to foster parents are
helping to buffer the difficulties.
o Ongoing effort to match children/youth to an appropriate foster placement occurs; yet, there are no full proof methods for ensuring
placements will not disrupt. Unplanned discharges occurred more than expected and has led to a decline in number of youth served
at present, even with the increase of client enrollments during 2019-2020. One unplanned client discharge was directly related to
COVID-19/shelter-in-place order.
o A few TFC providers have opted to move to only provide respite care or moved to proctor care with another Morrison program, which
has recently reduced TFC’s capacity”
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 Breakthrough and Counterpoint:
o “Proctor home recruitment and retention is a significant challenge. Breakthrough requires specially trained, attentive, and available
parents that are willing to be involved in the program’s daily operations. Currently, most day treatment services and proctor care is
suspended due to a lack of foster homes; capacity is 0. New proctor parent recruitment and certification is underway. We expect to
have 3 new proctor homes certified by the end of 2020.
o Due to limited funding, the Program no longer has a Proctor Manager and other staff have had to pick up these responsibilities.
o Youth referred to Breakthrough during the past two years have more acute health, mental health and SUD treatment needs and there
are limitations to what the juvenile court system can do to address these needs.
o Counterpoint requires specially trained, attentive, and available parents that are willing to be involved in the program’s daily
operations. Recruitment of foster homes is a challenge as many are hesitant to provide care for this specialized service.
o Currently, day treatment therapists need to have specialized training and supervision and be certified through the State of Oregon
Sexual Offending Treatment Board, but OYA and other funders do not recognize this expense. The Oregon Youth Authority contract
pays for services at BRS rates that are lower than treatment rates. As a result, the Program provides sexual offense treatment but is
not fully reimbursed for all costs.
o The impacts of the COVID-19 pandemic continue to be challenging for the Program. The emergency shut down and stay at home
orders resulted in CPDT program staff assuming the responsibilities of supervising and supporting educational services during the
spring and summer of 2020 and into the new school year. Educational services have been provided on-site without the support of
Portland Public Schools staff. Currently, youth are attending school via video conferencing at the CDPT site and Morrison staff
continue the role of supervising the school sessions.
o The emergency shut down also created a gap in CPDT food services. Our vendor stopped providing and delivering lunch to the
Program. This need was met through CPDT staff picking up daily free sack lunches provided by the School District.
o The impact of the COVID-19 pandemic has been challenging. Breakthrough staff have continued to provide education supports and
services without the PPS school staff onsite for the spring and summer of 2020 and into the new school year. Currently, the youth
are attending school via video conferencing at Breakthrough, and Morrison staff have taken on the role of supervising the school
sessions. Emergency shutdowns and stay-at-home orders also created a gap in Breakthrough food services as the vendor was no
longer able to cook and deliver lunch to the program. This need was met via daily pick up of free sack lunches offered by the school
district.”
 Paso:
o “During the past two years, the program has faced challenges due to level of care concerns and dilemmas. Many youth placed at
PASO by the Office of Refugee and Resettlement (ORR) have needed a higher level of care due to very serious mental health and/or
behavioral concerns. The populations referred seemed to need behavioral health residential treatment setting or highly secure,
locked settings that were unavailable. The PASO program has had to navigate these challenges by adapting the program to meet
the needs of individual youth or advocating for admission to a higher level of care. Simultaneously, ORR-funded programs like
PASO have been under pressure to respond to ORR policy mandates that require programs to transfer youth to a lower level of care
with specific timeframes. The challenge is that sometimes the youth are not ready for that quick transfer to a lower level of care, but
Federal policy requires it and does not take into full consideration each youth’s individual needs.
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o During the past year several youth in the program had aggressive outbursts and engaged in significant property damage. The
program has had to recover from property damage, and staff have had to recover from the traumatic experience of being involved in
these events.
o Staffing the program is challenging. Front-line milieu counselor positions require experience working with children and Spanish-
language proficiency (preferred) that is hard to acquire. The federal Office of Refugee and Resettlement requires an extensive
background check and fingerprinting that must be completed prior to employment. There are no allowances for preliminary
clearance. This process may take from 1-3 months depending on individual circumstances and the States in which they’ve
applicants have lived.
o COVID-19 has greatly affected the program by way of reduced referrals, changes in immigration policy, staffing concerns and limited
resources.”
 SAGE:
o “Limited capacity and length of stay has compounded the number of youth that are unable to access the program.
o Engagement is challenging for families that live out of County, and there exits a lack of appropriate resources and/or placement
options for youth transitioning out of care for this specific population of youth.”
 Residential Care Program Update-Long Term Group Home:
o “The Program faces difficulty in filling open direct service positions and encounters challenges with both recruitment and staff
retention.
o Food continues to be a challenge for the program. Serving youth from all over the world creates competing desires and preferences
about what kind of food is served. The Program is working with Morrison’s kitchen team to provide a variety of foods for the youth.
o Some youth decline a large amount of program services that they could benefit from.”
 Residential Care Program Update-Shelter:
o “Throughout the past two years Morrison has experienced significant challenges and delays in the process of hiring staff for the
Downtown Shelter program. Challenges have occurred in the following areas: recruiting and hiring direct service and management
staff with the qualifications necessary for the vacant positions, recruiting and hiring bi-lingual, Spanish-speaking staff including
management and clinical staff, and complying with new federal mandates to thoroughly screen job applicants and their criminal
backgrounds prior to hire. These processes have been time-consuming and full of delays making it challenging to maintain youth
supervision and coverage of all program operations. Staff resignations and staff turnover have put pressure on service delivery and
program operations. The Program Director position has been vacant for 1 ½ years, although Morrison was recently able to promote
the Assistant Program Director to the Program Director position.
o The COVID-19 pandemic has impacted youth and their length of stay in the program, creating delays in discharge and reductions in
referrals. Operational changes and CDC-recommended safety precautions have been implemented to respond prudently and safely
to COVID-19 i.e. screening individuals as they enter the building, marking spots for social distancing, required mask wearing,
frequent sanitizing, creating procedures and the physical space for quarantines and reducing the overall number of people in the
building. Staff concerns include feeling unsafe and that they do not want to put themselves or family members at risk.
13
o Increased media attention related to immigrant youth in 2019 and social unrest in downtown Portland near our facility in 2020 has
created anxiety for youth and staff.”
Changes that have occurred in the last 2 years: Individual program changes in the last two years identified by program managers.
 Planned Crisis Respite Foster Care:
o “Foster home recruitment and retention in the Portland metropolitan area continues to prove challenging, however efforts to
collaborate with the Foster Plus Collaborative and Morrison’s recent implementation of an advertising campaign, including social
media ads, have increased the pool of interested resource families.
o The numbers of children and youth have steadily declined in the past fiscal year (FY 21) due to the impact of COVID-19 and the
need to impose restrictions. Prior to the COVID-19 Pandemic the program was providing respite care to approximately 160 unique
children/youth with a total of 1549 nights. The Mid-Valley PCRC successfully recruited 10 respite homes and served approximately
55 during the two years that it was open. After struggling with start-up and funding problems, the program closed in March, 2020. To
be sustainable in the region the program needed to increase the amount of services provided and the number of homes. Additional
community development and start-up time was also needed.”
 Foster Care Program:
o “TFC as a program has had significant changes in the last two years. TFC moved to a new facility that is not as conducive to child
activities and has had a high rate of staff turnover. The program/agency has been resourceful to find Morrison locations that meet the
needs when changes occur and is in the process of building the Rotary Youth Center to support a child and family friendly
environment (construction should be complete in November this year).
o There have been some positive changes in staffing with the addition of a Division Director who has brought clinical insight and vision
to the program. The decision has been made to incorporate a licensed therapist to the team, along with implementation of the ARC
model to address and improve upon the Attachment, Regulation and Competency skills TFC is working to support for the clients and
their families. The addition of a Program Supervisor position has helped to strengthen support to the Case Managers. Other staff
changes occurred in our recruitment and certification team. A new recruiter/trainer was hired in April 2020, which was a vacant
position for 4 months, and before that in October 2019 a new certifier was hired. We feel confident that our program is stabilizing and
that we will continue to grow and refine ourselves in order to more effectively serve children and families.”
 Breakthrough and Counterpoint:
Breakthrough-
o “Construction was completed recently on a new recreation building located at next to the Morrison Sandy Boulevard building. Called
the Rotary Youth Center, it is sponsored and partially funded by the Rotary Club of Portland. It will provide additional indoor,
recreational space for youth to gather, socialize and exercise. It is also designed for open air activities on the patio and garden areas.
14
The new building is considered additional program space for the Breakthrough and Counterpoint Day Treatment and Proctor Care
program.
o The elimination of the proctor manager position created a need to re-organize how we recruit, train and supervise proctor families.
Recently, Breakthrough entered a partnership with Youth Progress to assist in recruitment of Breakthrough homes. We have three
(3) homes currently in the training and certification process and hope to take new referrals in November.
o Breakthrough has developed an Outpatient SUD treatment component and is able to accept SUD outpatient youth and families as
clients in addition to day treatment youth and families.”
Counterpoint-
o “The elimination of the proctor manager position created a need to re-organize how we recruit, train, and supervise proctor families.
Recently, the Morrison Breakthrough and Counterpoint programs entered a partnership with Youth Progress to assist in the
recruitment of new proctor care providers. We hope to achieve a small increase in the number of CPDT homes, perhaps by 1 or 2.”
 Paso:
o “A Behavior Support Specialist position was created to provide more therapeutic support for youth; this position is supervised by the
Clinical Supervisor.
o The program has undergone many facility improvements and renovations this year and has a fresh, new, inviting and youth-friendly
environment. Renovations include: New flooring in the entire building, new paint, murals throughout the building, new showers, new
anti-ligature furniture, new classroom design, new lighting on outside of building, office updates, door updates, window repairs and
updates, and internal wall improvements. Other renovations included: bathroom remodeling, living room remodeling (cabinets and
removal of fireplace), garden re-design and new external siding.
o PASO revamped its behavior management policy and updated behavioral management protocols to include more therapeutic
interventions drawn from the evidence-based, trauma informed Sanctuary Model.
o PASO created and implemented new, interdisciplinary Youth Support Teams to provide a multi-disciplinary plan that will support
youth in achieving reunification or transferring to a level of care that meets their needs.
o PASO revised its group curriculums and has implemented Power Source, Aggression Replacement Therapy groups, and Life Skills
groups on a weekly basis.
o A new Assistant Program Director was recently hired with six years of experience at Morrison including ORR programming.”
 SAGE:
o “Addition to the SAGE (Strength, Achievement, Growth, and Empowerment) program is a 4-bed program wing focused on safe and
supported community transition.
o Online educational program focused on credit recovery for credit deficient students is also a part of the program.
o An additional component which offers individual music, art, and language lessons as requested by clients.”
 Residential Care Program Update-Long Term Group Home:
15
o “Significant change occurred in leadership roles. While skilled staff, both the Program Director and the Assistant Program Director are
fairly new in their roles.
o The COVID-19 Pandemic has created the following program and operational challenges:
o Youth are no longer attending school in person
o Staffing challenges and concerns
o Limited community activities”
 Residential Care Program Update-Shelter:
o “Program enhancements included the addition of specialized positions to strengthen quality and improve compliance. The
new positions are: a Medical Services Supervisor, Overnight Milieu Supervisor, Residential Security Specialist (RSS), and
Kitchen Supervisor. Leadership positions (Program Director and Assistant Program Director) were recently filled.
o Quick and immediate implementation of infection control procedures that were required and recommended by local, state,
and federal authorities to control the spread of COVID-19. The Shelter has remained open to serve youth, at times only a
few, during the Pandemic.”
Lawsuits:
The Program Manager of PASO stated the following regarding a lawsuit, “Yes.: Lucas R., et al v. Azar, et al.
All Federal Staff Secure Programs in the U.S. were party to a lawsuit brought against the HHS Secretary Alex Azar. This was not specific to
Morrison. Our PASO staff secure program was included with all other ORR staff secure programs in the subpoena, and therefore Morrison was
required to respond. Of note, the lawsuit had nothing to do with the care that youth were receiving in ORR facilities. Morrison paid legal fees and
was reimbursed by the federal Office of Refugee and Resettlement. “
Grievances and complaints filed in the last two years: None in the past two years were reported.
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report Morrison Family Services, must submit a letter of verification indicating the agency is in compliance with the
specific rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency must
submit any and all specific documentation requested in the body of this report. The letter of verification and any additional requested documents can
be emailed directly to Holly.r.ivey@dhsoha.state.or.us or sent by regular mail to the following address:
Department of Human Services, Children’s Care Licensing Program
16
Attn: Holly Ivey, DHS Licensing Coordinator
201 High St SE, Suite 500
Salem, OR 97301
Recommendations: None
Exceptions: Yes, an exception was requested by Morrison for the windows of the residential facilities. The exception was for the following DHS
Licensing Rule: Room and Space Requirements Bedrooms 413-215-0516(3) (c) Outside room with window allowing egress from building
 Prior to the Licensing Renewal Process the agency submitted an exception request for the residential programs, as the windows do not allow egress. The
exception was approved until the next Licensing Renewal. Nothing further is required of Morrison regarding this rule.
Changes in License: None
Summary of Review
Program and Services Corrective Action
Yes No N/A Corrective Actions
413-215-0011(2) Completed
Program and services are in scope of license X
Governance of the Agency Corrective Action
Yes No N/A Corrective Actions
413-215-0021 Completed
(1)(a) Minimum of 5 board members X
(2)(f) Formally evaluate the exec. Director’s X
performance annually
(2)(g) Approves annual budget X
(2)(h) Obtain and review an annual X
independent financial review or audit of
financial records.
(2)(k) Written quality improvement program X
(2)(l) Meeting minutes X
Executive Director or Program Director Corrective Action
Yes No N/A Corrective Actions
413-215-0021 Completed
(3)(a) knowledge of requirements for X
providing care and treatment appropriate to
programs
(3)(g) Approval from BCU X
17
Discipline, Behavior Management, and Corrective Action
Yes No N/A Corrective Actions
Suicide Prevention 413-215-0076 Completed
(3) Agency uses appropriate and positive
methods of behavior management and
nationally recognized non-violent crisis X
intervention The agency utilizes NCI, and
Mandt.
(3)(b)(C) Agency does not use chemical and
mechanical restraint (excluding medically
X
necessary devices/prescriptions)
(3)(c) Agency uses appropriate time-out
rooms (adequate space, heat, light and
ventilation and is not capable of locking) and X
documents use in child’s record when
applicable
(3)(e) Agency uses seclusion
X
appropriately/consistent with policy
(4) Agency has adequate plan in place to
respond to suicidal behavior/warning signs X
Contractors (if applicable) Corrective Action
Yes No N/A Corrective Actions
413-215-0061(6) Completed
(a) Agency ensures the contractor meets the
requirements of this rule and Chapter 413 X
division 215
(b)(B) Contract includes the following:
(i) Services provided
(ii) Contractor fees
(iii) Disclosure of information from contractor
to agency
(iv) Lines of authority X
(v) Adherence to rules, including background
check
(vi) Any liability of the agency for acts of the
contractor, rights of indemnity and limitations
on liability
Supplemental Information Provided by Yes No N/A Corrective Actions Corrective Action
CCA Completed
Documents as indicated on the form titled
X
“Renewal Licensing Required Documents”
Documents as indicated on form titled
“Required Financial Documents and X
Information”
18
All required policies and procedures as
X
identified in the “Umbrella Rules”
All required policies and procedures as
identified in “Agency Type Specific Rules” X
Sage, Paso, Downtown Shelter Programs (Residential)
Physical Plant Corrective Action
Yes No N/A Corrective Actions
Completed
413-215-0046(3)(a) Foster Rights Posted (if X
children in DHS custody) Physical Plant 413-215-0511(2)(a) &(c) Buildings are
413-215-0051(1) Sufficient safe space, X smoke free, clean and in good repair (REPEAT FINDING
equipment, and office equipment 2019)
413-215-0091(12) License is posted in X
common area at each facility The following was identified in need of repair:
413-215-0001(5)(d), 0516(4(a)(I) & 0521(1) X Downtown Shelter:
Adequate furnishings and personal items  Some ceiling tiles were discolored in spots.
413-215-0511(2)(a) &(c) Buildings are X  Damage to a closet door punctured (about a two-inch
smoke free, clean and in good repair diameter.)
413-215-0511(2)(d) Rooms are free of X  Peeled paint around some of the bedroom door
harmful drafts, odors, and excessive noise frames.
413-215-0511(2)(e) Rooms are adequate in X  Black substance on a bathroom fan vent.
size and arrangement
413-215-0511(2)(f) System provides a X (Recommendation Only)
continuous supply of hot and cold water to SAGE/Paso:
taps located throughout the facility  Prior to the Licensing Review, the agency hired a
413-215-0511(2)(h) Building is well X professional company to treat the ceilings above the
ventilated and room temperature is within a showers for mold. There was a very slight
normal comfort range discoloration above a few showers, not dark enough
413-215-0516(1) All parts of the facility X to site as a finding. It is strongly recommended the
ensure the safety of children agency paint the bathroom ceilings with mold
blocking primer, and mold resistant paint, as this has
been a past Licensing finding.
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions
Bedrooms 413-215-0516(3) Completed
(a) Adequate furnishings and personal items X Room and Space Requirements Bedrooms 413-215-
(b) Separate from rooms used for dining, X 0516(3) (c) Outside room with window allowing egress
living, laundry, kitchen, and storage from building
(c) Outside room with window allowing X
egress from building  Prior to the Licensing Renewal Process the agency
(d) Ceiling at least 90 inches X submitted an exception request for the residential
19
(e) Minimum 60 SF per bed X programs, as the windows do not allow egress. The
(f) No more than 25 if dorm style X exception was approved until the next Licensing
(g) Permanently wired fixtures X Renewal. Nothing further is required of Morrison
(h) Window covering X regarding this rule.
(i) Beds are 3 feet apart and maintained to X
ensure safety
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions
Bathrooms 413-215-0516(4) Completed
(a)(A)&(B) 1:8 ratio for toilets and sinks X
(a)(D) Hot and cold running water, soap, and X
approved hand drying options
(a)(E) 1:10 ratio for shower or bathtub X
(a)(E) Individual privacy X
(a)(F) Window covering X
(a)(G) Permanently wired fixtures X
(a)(H) Adequate ventilation X
(b)&(c) Wooden racks on floors are X
prohibited and impervious shower mats are
disinfected & dried daily
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions
Kitchen 413-215-0516(6) Completed
(a) Used exclusively for storage, food X
preparation, dish washing, and activities
related to eating
(b) Walls, floors are easily cleanable X
(c) Equipment and utensils are easily X
cleanable, durable, nontoxic, and kept clean
(e) Equipment is easy to clean beneath, X
between and behind
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions
413-215-0516 Completed
(2) There is a separate living room or lounge X
area – 15 SF minimum per child
(5) There is a separate dining room with X
capacity for ½ of children in care and 15 SF
per child in care
(7) Laundry is separate from living areas, X
kitchen and dining
(8) Separate storage areas are provided for X
food, kitchen supplies, utensils, clean linens,
soiled linens and clothing, cleaning supplies
and equip, poisons, chemicals, outdoor
recreational and maintenance equipment
20
(9) Outdoor activity area is protected from X
vehicles and other hazards and of a size and
availability appropriate to the age and needs
of children in care
(11) & 413-215-0076(3)(c)(C) Time out X
rooms have adequate space, heat, light and
ventilation and is not capable of locking
Furnishings and Personal Items Corrective Action
Yes No N/A Corrective Actions
413-215-0521 Completed
(1) There is a bed with frame, clean mattress X
and pillow and personal storage (dresser,
closet)
(2) Linens are in good repair. There is a X
waterproof mattress cover or mattress.
Linens are appropriate and towels and
washcloths are provided
(3) Bedding is changed weekly or when X
soiled
(4) & (5) Personal hygiene supplies and X
appropriate clothing are provided
Food Services Corrective Action
Yes No N/A Corrective Actions
413-215-0536(1)&(2) Completed
(1)(a) Meals are arranged daily, consistent X
with normal mealtimes that occur during the
hours of operation
(1)(b) Menus are prepared in advance in X
accordance with USDA guidelines, 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 X
sanitary manner
(2)(c) & (d) Food products are obtained from X
commercial suppliers (exception of fruits &
vegetables), unpasteurized juice is
prohibited, and only Grade A pasteurized
and fortified milk in appropriate container.
Safety Corrective Action
Yes No N/A Corrective Actions
413-215-0541 Completed
(2)(a) Written emergency plan X
(2)(b) Telephone numbers for local police X
and fire are posted near all telephones
21
(2)(c) Operative flashlights sufficient in X
number are readily available to staff
(3)(a) Evacuation drill occurs monthly under X
varying conditions, is retained 2 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
(G) problems encountered
(H) time to complete
Safety – Transportation Corrective Action
Yes No N/A Corrective Actions
413-215-0541 Completed
(5)(b) Vehicle has insurance policy, is smoke X
free, safe operating condition, and has first
aid kit and fire extinguisher 2-A:10-BC
Medication Corrective Action
Yes No N/A Corrective Actions
413-215-0551 Completed
(3)&(7)(e) Medications have a prescription X Medication 413-215-0551(10) Written record of the
and are stored in the original container with administration of medication includes: (f) method of
prescription label administration (i) medication taken outside facility
(4)&(5) Herbal supplements and remedies, X
medical treatments, special diets, physical  (SAGE)The above required information was not
therapy, physical aides or limitations have a found on the medication records.
written order signed by a physician or
qualified medical professional.
(7)(c) Medications are inaccessible to X
children
(8) Medications are disposed in accordance X
with state and federal law
(9) Written record of the disposal of
medications is maintained and includes:
(a) description and amount
(b) name
(c) reason
(d) method
(e) staff & witness signature
(10) Written record of the administration X
of medication includes:
(a) name
(b) description
(c) dates and times
(d) missed doses
22
(e) medication disposed
(f) method of administration
(g) ID of person administering
(h) possible adverse reactions
(i) medication taken outside facility
Extracurricular, Enrichment, Cultural &
Corrective Action
Social Activities Yes No N/A Corrective Actions
Completed
413-215-0554
(2) Children have ongoing opportunities to X
participate in at least one age-appropriate or
developmentally appropriate activity
Minimum Staffing Requirements Corrective Action
Yes No N/A Corrective Actions
413-215-0561 Completed
(1) &(2) Supervision is adequate for the type X
of program, location, age and type of
children, ability of supervisor to respond,
electronic back-up systems.
Minimum ratios are maintained:
Under 30 months of age: 1:4
30 months to ˃ 6 yrs or non-ambulatory: 1:6
Ages 6 and older: 1:7
Overnight (staff awake)
1:10
(4)(a) When one staff on duty, there is X
additional staff immediately available with
max response time of 30 minutes
(5) There is at least one on-site employee X
authorized to apply the reasonable and
prudent parent standard
Separation of Residents Corrective Action
Yes No N/A Corrective Actions
413-215-0566 Completed
(1) Children are in separate bedrooms than X
adults, unless parent and child, or there is
written approval from guardian/parent and
licensing coordinator
(2) There is adequate supervision of children X
if both males and females are served by the
program
23
Personnel Files Corrective Action
Yes No N/A Corrective Actions
413-215-0061 Completed
Staff Name/Position X
(3)(g) Date of Hire X
(3)(a) record of education, training and X
previous employment
(1)(b) & (3)(b) reference checks completed X
and documented
(1)(a) & (3)(c) Background check completed X
and documented
(3)(d) Annual performance evaluations X
(3)(f) Record of personnel actions X
(3)(g) Termination date, reason for X
termination
(3)(h) Current job description (1)(c) X
Employee meets minimum qualifications
stated in current job description
New Employee Orientation – Umbrella
Corrective Action
Requirements (30 days) Yes No N/A Corrective Actions
Completed
413-215-0061(4)
(a) Agency policies and procedures X
(b) Ethical and professional guidelines X
(c) Organizational lines of authority X
(d) Attributes of population served X
(e) & (5)(a) to (c) Mandatory reporting that X
includes:
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter 106,
section 36
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
(f) Privacy laws X
(g) Emergency procedures X
New Employee Orientation – Residential
Corrective Action
(30 days) Yes No N/A Corrective Actions
Completed
413-215-0556
(1)(a) Discipline and behavior management X
including de-escalation, crisis prevention,
positive behavior management, and
24
disciplinary techniques that are non-punitive
in nature
(1)(b) Restraint and seclusion (if applicable) X
Ongoing Training Corrective Action
Yes No N/A Corrective Actions
Completed
413-215-0536(2)(b) Employees who handle X Ongoing Training 413-215-0556(2)(c) Discipline and
food served to children have a valid food Behavior Management
handler’s card
413-215-0541(5)(a) Employees transporting X  (SAGE and Paso) The above required information
children have: current driver’s license,
was not consistently found in the training records.
insurance, trained in emergency procedures
and behavior management, and training for
Ongoing Training 413-215-0556(4) Designated staff
15+ passenger vans if applicable)
authorized to apply reasonable and prudent parent
413-215-0556(2)(a) Environmental X
standard are trained in application of the standard
emergencies
413-215-0556(2)(b) Universal Precautions X  (SAGE and Paso) The above required information
413-215-0556(2)(c) Discipline and was not consistently found in the training records.
X
Behavior Management
413-215-0556(3) Staff providing direct care X
Ongoing Training 413-215-0061(5) Mandatory reporting
must maintain current CPR/First Aid
(annually) that includes:
certification
(a) legal definition of child abuse ORS 419B.005, Oregon
413-215-0556(4) Designated staff Laws 2016, chapter 106, section 36
authorized to apply reasonable and (b) legal responsibility to immediately report
X
prudent parent standard are trained in (c) legal responsibility to report is personal to the
application of the standard employee
413-215-0061(5) Mandatory reporting
(annually) that includes:  Paso had one employee file that was missing
(a) legal definition of child abuse ORS documentation of the above required training in
419B.005, Oregon Laws 2016, chapter 106, X 2020.
section 36
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
Contractors (if applicable) Corrective Action
Yes No N/A Corrective Actions
413-215-0061(6) Completed
(a) Agency ensures the contractor meets the
requirements of this rule and Chapter 413 X
division 215
(b)(B) Contract includes the following:
(i) Services provided X
(ii) Contractor fees
25
(iii) Disclosure of information from contractor
to agency
(iv) Lines of authority
(v) Adherence to rules, including background
check
(vi) Any liability of the agency for acts of the
contractor, rights of indemnity and limitations
on liability
Children’s Records Corrective Action
Yes No N/A Corrective Actions
Completed
Name X
Health Services
413-215-0546
(2) Medical history obtained within 30 days X
(significant findings, current immunizations,
history of surgical procedures-health issues-
injuries, allergies, dental, vision, hearing,
behavioral health, and physician orders)
(2)(e) Documentation of age appropriate X
instruction – pregnancy prevention, nutrition,
prevention of HIV & AIDS, and prevention
and treatment of sexually transmitted
disease
(4)(a) to (f) Medical exams (3 in first year of X
life, 2,4,6,9,14)
Consents Corrective Action
Yes No N/A Corrective Actions
413-215-0576(1) Completed
(a) Provide routine and emergency medical X
care
(b) Use the discipline and behavior X
management system
(c) Use restraint or seclusion (if applicable). X
Must specify the reasons for the intervention
and how staff are trained and supervised
(d) Restrict contact with persons outside of X
the agency
26
(e) Allow access as defined in 413-215- Consents 413-215-0576 (1) (e) Allow access as defined in
X
0091 & 0101 413-215-0091 & 0101(g) Apply the reasonable and
prudent parent standard.
(f) Impose a dress code X
(g) Apply the reasonable and prudent X  (SAGE) The above required information was not
parent standard found on the consents.
Disclosures
Corrective Action
413-215-0576(2) Parent/guardian has Yes No N/A Corrective Actions
Completed
acknowledged in writing:
(a) Information regarding personal or room X
searches and protocols for confiscation of
contraband
(b) Statement of Rights of Children and X
Parents/Guardians
(c) Any policies and procedures upon X
request
Authorizations Corrective Action
Yes No N/A Corrective Actions
413-215-0576(3) Completed
(a) Disclose or exchange information with X
others
(b) Child specific visitors X
(c) Visitation resources are pre-approved X
(d) Activity specific authorizations are pre- X
approved to allow children to participate in
potentially hazardous activities, including but
not limited to using motorized yard
equipment, swimming, and horseback riding.
Information about Children in Care
Corrective Action
413-215-0581(1) Summary sheet contains Yes No N/A Corrective Actions
Completed
the following:
(a)The name, gender, date of birth, Information about Children in Care 413-215-0581(1)
X
religious preference, and previous address Summary sheet contains the following: (a) religious
(b) Name and location of previous and preference (b) Name and location of current and
X
current school previous school (e) The name, address, and
(c) Date of admission X telephone number of: (C) Other persons significant to
(d) Legal custody X child. (D) Other professionals to be involved in
service planning (if applicable)
(e) The name, address, and telephone
number of:
 SAGE: The above required information (a,b,e,C,D).
(A) The child in care's parents. X
was not consistently found in the files reviewed.
(B) The child in care's legal guardian, if
Religious preference was always left blank on the
different than the parents, and a copy of
form in the files reviewed.
27
the document that provides for his or her  Paso: Missing religious preference and previous
authority over the child in care. address.
(C) Other persons significant to child  Downtown Shelter and Residential Programs:
(D) Other professionals to be involved Missing religious preference.
in service planning (if applicable)
Service Planning Corrective Action
Yes No N/A Corrective Actions
413-215-0581(2) Completed
(b) Intake document is completed the date X Service Planning 413-215-0581(2) (e) (A)&(B) Service
child accepted into care (emergency plan within 60 days (parent, guardian and child actively
placement 48 hours) involved). Describes how child’s issues will be
addressed, anticipated outcomes and reviewed by child
(d) Assessment is completed within 30 days X
and guardian/parent.
and contains relevant historical info., current
behavioral observations, identified need for
services, and how agency will provide  (PASO) The above required information was not
found in the files reviewed. The service plans did not
services
list issues to be addressed or anticipated outcomes.
(e) (A)&(B) Service plan within 60 days
They only listed mandatory services to be provided.
(parent, guardian and child actively
involved). Describes how child’s issues
X
will be addressed, anticipated outcomes
Service Planning 413-215-0581(2)(e)(C) &(D) Service plan
and reviewed by child and
is reviewed quarterly and revised when information
guardian/parent.
indicates other services should be provided.
(e)(C) &(D) Service plan is reviewed  (SAGE) The above required information was not
quarterly and revised when information found in the files reviewed. Service plans were
X
indicates other services should be reviewed and revised by the program every 6
provided months.
Case Management Corrective Action
Yes No N/A Corrective Actions
413-215-0581(3) Completed
(a) Services are documented, progress Case Management 413-215-0581(3) (a) Services are
X
toward achieving goals is tracked documented, progress toward achieving goals is tracked
(b)-(d) discharge planning and instructions
(b)-(d) discharge planning and
X
instructions
 Services: (SAGE) The above required information
X
was not consistently found in the files reviewed. The
service goals were adequate, however the plans
lacked detail regarding the progress towards
(f) Incident Reports
achievement of goals
.
 Discharge Planning: (SAGE) Minimal discharge
information was found on the discharge summaries.
28
The summaries lacked: current providers, medical
appointments and medication information.
Financial Records Corrective Action
Yes No N/A Corrective Actions
413-215-0581(4) Completed
Records contain date, amount, source,
X
purpose, signatures
Personal Possessions Records Corrective Action
Yes No N/A Corrective Actions
413-215-0581(5) Completed
Individual written inventory of all personal
possessions is maintained and updated as X
needed
Records and Documentation Corrective Action
Yes No N/A Corrective Actions
413-215-0071 Completed
(1) Stored safely X
(2) Permanent, legible, dated, and signed X
(3)&(4) Uniform in organization, readily X
identifiable and accessible, current, and
complete, containing all required info. No
eraser tape or white out.
(7) Permanent registry for each child
includes:
Name
Gender
X
Birth date
Names, addresses of parents or guardians
Dates of admission
Placement upon discharge
Breakthrough and Counter Point Programs (Day Treatment)
Educational Services Corrective Action
Yes No N/A Corrective Actions
413-215-0856 Completed
(1) Complies with the minimum requirements X
for private education as determined by Dept.
of Education
29
School is registered with Dept. of Education X
(if applicable)
School is accredited X
Accrediting body DART- Portland Public
(2) 1:15 ratio for qualified teacher/children X
(3) Curriculum meets OAR 581-022-1020 X
(4) Secondary schools – verification provided X
that meets academic standards to obtain
admission to higher education and receive
high school diploma or GED
Physical Plant Corrective Action
Yes No N/A Corrective Actions
Completed
413-215-0046(3)(a) Foster Rights Posted (if X
children in DHS custody)
413-215-0051(1) Sufficient safe space, X
equipment, and office equipment.
413-215-0816(8)(e) Adequate in size and X
arrangement for programs offered
413-215-0091(12) License is posted in X
common area at each facility
413-215-0001(5)(d) & 0816(9)(a)&(b) X
Adequate furnishings and personal items;
storage for personal items
413-215-0816(2) Buildings are smoke free, X
clean and in good repair
413-215-0816(3) Rooms are free of harmful X
drafts, odors, and excessive noise
413-215-0816(4) Rooms are adequate in X
size and arrangement
413-215-0816(5) System provides a X
continuous supply of hot and cold water
413-215-0816(7) Building is well ventilated X
and room temperature is within a normal
comfort range
Bathrooms Corrective Action
Yes No N/A Corrective Actions
413-215-0816(8)(a) Completed
(A) 1:15 ratio for toilets X
(B) 1:2 ratio for sinks to toilets. Hand- X
washing sink not used for food prep
(C) Hot and cold running water, soap, and X
approved hand drying options
(D) Individual privacy X
30
(E) Permanently wired fixtures X
(F) Window covering X
(G) Mirror, permanently affixed X
(H) Adequate ventilation X
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions
Completed
413-215-0816(8)(A)(B) Laundry is separate X
from food storage, kitchen and dining
413-215-0816(8)(c) Separate storage areas X
are provided for food, kitchen supplies,
utensils, clean linens, soiled linens and
clothing, cleaning supplies and equip,
poisons, chemicals, outdoor recreational and
maintenance equipment
413-215-0816(8)(g) Recreational activity X
area is protected from vehicles and other
hazards and of a size and availability
appropriate to the age and needs of children
in care
413-215-0816(8)(f) Time out rooms have X
adequate space, heat, light and ventilation
and is not capable of locking
Food Service area Corrective Action
Yes No N/A Corrective Actions
413-215-0816(8)(d) Completed
(A) Areas used for storage, food preparation, X
and dish washing are separate from child-
caring areas
(B) Walls, floors are easily cleanable X
(C) Equipment and utensils are easily X
cleanable, durable, nontoxic, and kept clean
(D) Equipment is easy to clean beneath, X
between and behind
Food Services Corrective Action
Yes No N/A Corrective Actions
413-215-0831 Completed
(1)(a) Meals are arranged daily, consistent X
with normal mealtimes that occur during the
hours of operation
(b) Menus are prepared in advance in X
accordance with USDA guidelines, provide a
variety of foods and are adjusted for
seasonal changes.
(b) Menus are maintained for at least 6 X
months Lunch is catered by the school
district and brought in prepared.
31
(c) Drinking water is freely available X
(2)(a) Food is stored, prepared & served in a X
sanitary manner
(2)(c) & (d) Food products are obtained from X
commercial suppliers (exception of fruits &
vegetables), unpasteurized juice is
prohibited, and only Grade A pasteurized
and fortified milk in appropriate container.
Lunch is catered by the school district
and brought in prepared.
(2)(e) Children are supervised when in the X
food-preparation area
Safety Corrective Action
Yes No N/A Corrective Actions
413-215-0836 Completed
(2)(a) Written emergency plan X
(2)(b) Telephone numbers for local police X
and fire are posted near all telephones
(2)(c) Operative flashlights sufficient in X
number are readily available to staff
(3)(a) Evacuation drill occurs monthly X
under varying conditions, is retained 2
years and contains;
(A) identity of person conducting drill
(B) date & time
(C) notification method
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
(4) Children are protected from hazards and X
potential hazards
(4)(c) Light fixtures have protective covers X
Safety – Transportation Corrective Action
Yes No N/A Corrective Actions
413-215-0836(5) Completed
(b) Vehicle has insurance policy, is smoke X
free, safe operating condition, and has first
aid kit and fire extinguisher 2-A:10-BC
Medication Corrective Action
Yes No N/A Corrective Actions
413-215-0846 Completed
(2) & (5)(e) Medications have a prescription X Medication 413-215-0846 (8) Written record of the
and are stored in the original container with administration of medication includes:(h) possible
prescription label adverse reactions (i) medication taken outside facility
(5) Medications are kept in locked storage X (REPEAT FINDING 2019)
32
(6) Medications are disposed in accordance X
with state and federal law
(7) Written record of the disposal of X  The above required information was not found on the
medications is maintained (description, medication administration records at Breakthrough
name, reason, method, staff & witness and Counterpoint.
signature)
(8) Written record of the administration of
X
medication includes:
(a) name
(b) description
(c) dates & times
(d) missed doses
(e) medication disposed
(f) method of administration
(g) ID of person administering
(h) possible adverse reactions
(i) medication taken outside facility
Staff Qualifications and Minimum Staffing
Corrective Action
Requirements Yes No N/A Corrective Actions
Completed
413-215-0811
(1) Teachers are licensed in accordance with X
Teachers Standards and Practices
Commission
(2) A qualified clinical supervisor directs the X
clinical program and supervises clinical staff
(3) Mental health service delivery staff meet X
the qualifications in OAR 309-022-0125
(4) Sufficient QMHP and other staff to meet X
the severity and acuity of children served.
Does not exceed 1:12 QMHP
Current Ratios 2:15
413-215-0001(5)(f) Ensures safety and X
adequate supervision
413-215-0001(5)(c) Engages in and applies X
appropriate behavior management
techniques
Personnel Files Corrective Action
Yes No N/A Corrective Actions
413-215-0061 Completed
33
Name X
Position X
(3)(g) Date of Hire X
(3)(a) record of education, training and X
previous employment
(1)(b) & (3)(b) reference checks complete X
and documented
(1)(a) & (3)(c) Background check was X
completed and documented
(3)(d) Annual performance evaluations X
(3)(f) Record of personnel actions X
(3)(g) Termination date, reason for X
termination
(3)(h) Current job description (1)(c) X
Employee meets minimum qualifications
stated in current job description
New Employee Orientation- Umbrella
Corrective Action
Requirements (30 days) Yes No N/A Corrective Actions
Completed
413-215-0061(4)
(a) Agency policies and procedures X
(b) Ethical and professional guidelines X
(c) Organizational lines of authority X
(d) Attributes of population served X
(e) & (5)(a) to (c) Mandatory reporting that X
includes:
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter 106,
section 36
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
(f) Privacy laws X
(g) Emergency procedures X
Ongoing Training Corrective Action
Yes No N/A Corrective Actions
Completed
413-215-0831(2)(b) Employees who handle X
food served to children have a valid food
handler’s card
413-215-0061(5) Mandatory reporting X
(annually) that includes:
34
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter 106,
section 36
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
413-215-0836(5)(a) Employees transporting X
children meet the driver requirements
(current driver’s license, insurance, trained in
emergency procedures & behavior
management, and training for 15+
passenger vans if applicable)
Contractors (if applicable) Corrective Action
Yes No N/A Corrective Actions
413-215-0061(6) Completed
(a) Agency ensures the contractor meets the
requirements of this rule and Chapter 413 X
division 215
(b)(B) Contract includes the following:
(i) Services provided
(ii) Contractor fees
(iii) Disclosure of information from contractor
to agency
(iv) Lines of authority X
(v) Adherence to rules, including background
check
(vi) Any liability of the agency for acts of the
contractor, rights of indemnity and limitations
on liability
Children’s Records Corrective Action
Yes No N/A Corrective Actions
Completed
Name of Child X
Date of admission X
Medication Corrective Action
Yes No N/A Corrective Actions
413-215-0846 Completed
(3) Medical treatments, special diets, X
physical therapy, physical aides or
35
limitations have a written order signed by a
physician or qualified medical professional.
(4) Self-administration is approved in writing X
by Physician, recommended by agency, and
monitored by staff or guardian. (9) If
applicable, there is documentation of the
continuing evaluation of the ability of the
child to self-administer medication
(8) Medication record X
Records and Documentation Corrective Action
Yes No N/A Corrective Actions
413-215-0071 Completed
(1) Stored safely and are available for X
inspection by Dept.
(2) Permanent, legible, dated, and signed X
(3)&(4) Uniform in organization, readily X
identifiable and accessible, current, and
complete, containing all required info. No
eraser tape or white out.
(7) Permanent registry for each child
includes:
Name
Gender
X
Birth date
Names, addresses of parents or guardians
Dates of admission
Placement upon discharge
Treatment Foster Care
Medication Corrective Action
Yes No N/A Corrective Action
413-215-0381 Completed
(2) &(5)(e) Medications have a prescription X
and are stored in the original container with
prescription label
(3) Medical treatments, special diets, X
physical therapy, physical aids or limitations
36
have a written order signed by a physician or
qualified medical professional.
(4) Self-administering medications by a child X
is approved in writing by physician,
recommended by agency, and closely
monitored
(6) Medications are disposed in accordance X
with state and federal law
(7) Written record of the disposal of X
medications includes:
(a) description
(b) name
(c) reason
(d) method
(e) staff & witness signature
(10) Written record of the administration of X
medication includes:
(a) name
(b) description
(c) dates, times
(d) missed doses
(e) medication disposed
(f) method of administration
(g) ID of person administering
(h) possible adverse reactions
(i) medication taken outside facility
Placement of a Child by Agency Corrective Action
Yes No N/A Corrective Action
413-215-0356 Completed
(2) Placement is consistent with X
recommendations in the current home
assessment
(3) Home does not exceed: X
(a) 4:1 ratio approved proctor foster parent
(b) 7:2 ratio approved proctor foster parents
(c) 2 children under age of 3
(6) At time of placement the agency provides X
proctor foster home parents with:
(a) Child’s name, date of birth and reason for
placement
(b) Name and phone# of assigned worker
(c) Information on health, behavioral
characteristics and needs of child
(d) Authorization and written instructions for X
obtaining medical, dental and other and
emergency care
37
Respite Care Corrective Action
Yes No N/A Corrective Action
413-215-0366 Completed
(1) Agency has and adheres to a respite care X
policy
(2)(a) Alternate caregivers are X
(A) at least 21 years of age and
(B) have completed background checks
(2)(b) Agency approval is received prior to X
using respite care
(2)(c) Proctor foster home notifies agency in X
advance when providing respite care that will
exceed max number of children authorized
(2)(d)&(e) Respite care plan for each child X
and includes emergencies
Records of Proctor Foster Homes Corrective Action
Yes No N/A Corrective Action
413-215-0351 Completed
Last Name of Proctor Foster Parent(s) X
(2)(a) Certificate that includes: age range of X
children, restrictions or limitations, and
statement that the home meets standards
established in these rules
(2)(b) & 413-215-0316(4) Notification of X
acceptance or denial of application. If denial
is due to substantiated abuse, the reason for
denial is disclosed to applicant.
(2)(d) All documents pertaining to formal X
complaints. See also 413-215-0336
(2)(e) and 413-215-0356(5) Signed contract X
(2)(f) List of all children placed that includes X
identifying and placement information
413-215-0356(4) Documentation of the basis
for placement
(2)(g) Documentation of home visit (every X
180 days)
(3) Documentation of changes in address, X
name and household composition, and
exceptions or suspensions
(4) Documentation of inactive status (if X
applicable)
413-215-0313(1)(a) at least 21 years of age X
38
413-215-0341 Written notice to proctor foster X
home if decertified
413-215-0349(1)-(7) Required notifications X
Assessment and Approval of Proctor
Foster Homes Corrective Action
N/A Corrective Action
Written Assessment Completed
413-215-0316
(1)&(2) Assessment is based on an on-site X
review of the home, observations and
interviews of each household member,
background check, any information gathered
during assessment.
(2)(a) Application signed by all applicants X
(2)(b) Home is primary residence and where X
each child will reside
(2)(c) Statement of physical and mental X
health
(2)(d) Report from licensed health care or X
mental health professional if determined
appropriate by agency
(2)(e) Minimum of 4 references (only one can X
be relative)
(2)(f) Contact information for 2 individuals if X
applicant displaced by natural disaster
Assessment and Approval of Proctor
Foster Homes
Corrective Action
Written Home Study includes the Yes No N/A Corrective Action
Completed
following:
413-215-0316(3)
(a) Standards for the Proctor Foster Home X
413-215-0318 – Safety Assessment
(CF0979) although form is no longer required
in rule, it may be accepted but must also
include evidence the following has been
addressed:
(1)(a) Home is primary residence
(1)(d) For children in custody of the
Department, the home must post and
comply with the Foster Children’s Bill of
Rights
(1)(g) Authorization must be received
from the agency prior to the beginning of
hunting or target practice by the child
(2)(a) If there are potential hazards in or
around the home, a plan to prevent
39
exposure of the child to the hazard must
be developed and approved by the
agency
(2)(a) Space heaters must be plugged
directly into a wall outlet and equipped
with top-over protection
(2)(d) Home and furnishings must be
clean and in good repair and grounds
must be maintained
(2)(e) No accumulation of garbage or
debris
(2)(f) Home has an adequate source of
safe water to be used for personal
hygiene
(2)(g) There is a provision for safe
storage and administration of all
medications in the household
(2)(i)(A)Children may not be exposed to
any second-hand smoke in home or
vehicle.
(2)(i)(B) Household members may not
provide any form of tobacco, nicotine, or
other product illegal for a minor to
possess
(2)(i)(C) All products referenced in (B)
must be stored safe and in a manner
inaccessible to children
(4)(d) Written authorization must be
received by proctor foster home prior to
transporting a child out of state or country
(4)(e) Proctor foster home must request
approval from Department no less than
90 days prior to international travel
(b) Names and ages of children in the home X
and children no longer in the home
(c) Background check for all household X
members over 18 and those under 18 as
determined appropriate
(d) Background check from every state (or X
country) of residence in last 5 years for
household members over 18 and those
under 18 as determined appropriate
(e) Placement preferences X
40
Assessment and Approval of Proctor Foster Homes
Written Home Study includes the following:
413-215-0316(3) (g) Life experiences and challenges(h)
Relevant health history (j) Employment and finances(k)
Current support systems and need for additional support
services(l) Marital history, including previous marriages,
divorces, and long-term relationships (m) Parenting skills
and values (o) Religion or spiritual beliefs (p) Cultural
background and experiences with diverse cultural groups
(q) Ability to respect spiritual beliefs, sexual orientation,
gender identity, and gender expression, disabilities,
national origin, and cultural identities of each child and
provide opportunities to enhance the positive self-
concept and understanding of child’s heritage
414-The above required information in the home studies
reviewed lacked adequate detail.
(f) Motivation for providing foster care X
(g) Life experiences and challenges X
(h) Relevant health history X
(i) Education and training X
(j) Employment and finances X
(k) Current support systems and need for X
additional support services
(l) Marital history, including previous X
marriages, divorces, and long-term
relationships
(m) Parenting skills and values X
(n) Lifestyle X
(o) Religion or spiritual beliefs X
(p) Cultural background and experiences X
with diverse cultural groups
41
(q) Ability to respect spiritual beliefs, X
sexual orientation, gender identity, and
gender expression, disabilities, national
origin, and cultural identities of each child
and provide opportunities to enhance the
positive self-concept and understanding
of child’s heritage
(r) Assessment of current and previous X
licenses, certifications and other applications
for providing care including adults.
Information must include any denials,
suspensions revocations, or terminations
(s) Assessment of the areas in which training X
is needed and the plan of the agency for
providing needed training and timeframes
(t) Applicant’s home and community X
(u) Assessment and recommendations X Assessment and Approval of Proctor Foster Homes
including the characteristics and Written Home Study includes the following:
maximum number of children who may be 413-215-0316(3) (u) Assessment and recommendations
placed in care including the characteristics and maximum number of
children who may be placed in care
 The above required information in the Assessment
and recommendation reviewed lacked adequate
detail regarding characteristics of children to be
placed in the homes.
Annual Review and Approval Corrective Action
Yes No N/A Corrective Action
413-215-0331(2) Completed
(a) Updated home study X
(b) Background check(s) X
(d) Out of state background check (if X
applicable)
(e) Documentation that home remains in X
compliance with safety standards 413-215-
0318
(f) Recommendation to approve or deny re- X
issuance of certificate
Orientation for Proctor Foster Homes
Corrective Action
Applicants Yes No N/A Corrective Action
Completed
413-215-0321(2)
(a) & 413-215-0061(4)(a) Policies and X
procedures of the agency
42
(b) & 413-215-0061(4)(d) Attributes of X
population. Needs and characteristics of
children needing placement
(c) Attachment, separation, and loss X Orientation for Proctor Foster Homes Applicants 413-
issues for children and families 215-0321(2) (c) Attachment, separation, and loss issues
for children and families
 Documentation of the above required orientation was
not consistently found in the files reviewed.
(d) Importance of cultural identity and ways X
to foster this identity
(e) Impact of foster care on child and family X
(f) Rights and responsibilities of proctor X
foster parent and agency
(g) Resources available X
(h) Confidentiality X
(i) Rights of families and children X
(j) Provided copies of X
(A) Program statement
(B) Requirements for Proctor Homes
(C) Policies of agency governing proctor
foster homes
(D) Training requirements
(E) Licensing rules
(F) Expectations for working with the
agency
Orientation – Umbrella Requirements (30
Corrective Action
days) Yes No N/A Corrective Action
Completed
413-215-0061(4)
(b) Ethical and professional guidelines X
(c) Organizational lines of authority X
(e) & (5)(a) to (c) Mandatory reporting that X
includes:
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter 106,
section 36
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
(f) Privacy laws X
(g) Emergency procedures X
Training for Parents in Proctor Foster Corrective Action
Yes No N/A Corrective Action
Care Completed
43
Written Training Plan includes:
413-215-0326(1)
(a) Minimum of 15 hours of training before X
placement
(b) Minimum of 15 hours training annually X
prior to approval
(c)(A) Characteristics and needs of children X
who are placed
(c)(B) Ways to effectively parent children, X Training for Parents in Proctor Foster Care
including application of the reasonable Written Training Plan includes:
and prudent parent standard 413-215-0326(1) (c)(B) Ways to effectively parent
children, including application of the reasonable and
prudent parent standard
 Documentation of the above required training was
not consistently found in the files reviewed.
(c)(C) Positive behavior management X
(c)(D) Importance of family of the child X Training for Parents in Proctor Foster Care
and working with the family Written Training Plan includes:
413-215-0326(1) (c)(D) Importance of family of the child
and working with the family
 Documentation of the above required training was
not consistently found in the files reviewed.
(c)(E) Importance of age-appropriate or X
developmentally appropriate extracurricular,
enrichment, cultural, and social activities
(c)(F) Preparation of child for X Training for Parents in Proctor Foster Care
independence based on age, stage of Written Training Plan includes:
development, and child’s needs 413-215-0326(1) (c)(F) Preparation of child for
independence based on age, stage of development, and
child’s needs
 Documentation of the above required training was
not consistently found in the files reviewed.
(c)(G) Legal responsibility to report X Training for Parents in Proctor Foster Care
suspected child abuse Written Training Plan includes:
413-215-0326(1) (c)(G) Legal responsibility to report
suspected child abuse
 Documentation of the above required training was
not consistently found in the files reviewed.
44
(2) Training is documented X
Personnel Files Corrective Action
Yes No N/A Corrective Action
413-215-0061 Completed
Staff Name X
Position X
(3)(g) Date of Hire X
(3)(a) record of education, training and X
previous employment
(1)(b) & (3)(b) reference checks completed X
and documented
(1)(a) & (3)(c) Background check X
completed and documented
(3)(d) Annual performance evaluations X
(3)(f) Record of personnel actions X
(3)(g) Termination date, reason for
X
termination
(3)(h) Current job description X
New Employee Orientation – Umbrella
Corrective Action
Requirements (30 days) Yes No N/A Corrective Action
Completed
413-215-0061(4)
(a) Agency policies and procedures X
(b) Ethical and professional guidelines X
(c) Organizational lines of authority X
(d) Attributes of population served X
(e) & (5)(a) to (c) Mandatory reporting X
(annually) that includes:
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter
106, section 36
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal
to the employee
(f) Privacy laws X
(g) Emergency procedures X
45
New Employee Orientation – Foster
Corrective Action
Care (30 days) Yes No N/A Corrective Action
Completed
413-215-0371
(1)(a) Discipline and behavior management X
including de-escalation, crisis prevention,
positive behavior management, and
disciplinary techniques that are non-
punitive in nature
(1)(b) Restraint and seclusion (if X
applicable)
Ongoing Training Corrective Action
Yes No N/A Corrective Action
Completed
413-215-0371(2)(a) Environmental X
emergencies
413-215-0371(2)(b) Universal Precautions X
413-215-0371(2)(c) Discipline and X
Behavior Management
413-215-0371(3) Maintain current X
CPR/First Aid certification
413-215-0371(4) Training related to the X
reasonable and prudent parent standard
and developmentally appropriate activities
413-215-0061(5) Mandatory reporting that X
includes:
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter
106, section 36
(b) legal responsibility to immediately
report
(c) legal responsibility to report is personal
to the employee
Contractors (if applicable) Corrective Action
Yes No N/A Corrective Action
413-215-0061(6) Completed
(a) Agency ensures the contractor meets
the requirements of this rule and Chapter X
413 division 215
(b)(B) Contract includes the following:
(i) Services provided
(ii) Contractor fees
X
(iii) Disclosure of information from
contractor to agency
(iv) Lines of authority
46
(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
Children’s Records Corrective Action
Yes No N/A Corrective Action
Completed
Name
X
Initial Evaluation Corrective Action
Yes No N/A Corrective Action
413-215-0386(2) Completed
(a) Agency request and review all available X
reports of child’s past and present
behavior, educational status, and physical
and mental health.
(b) Preliminary determination whether X
prospective child has disorders,
disabilities, or deficits for which care,
supervision, training, rehab, or treatment is
needed
Information about Children in Care
Corrective Action
413-215-0396 (1) Summary sheet Yes No N/A Corrective Action
Completed
contains the following:
Information about Children in Care 413-215-0396 (1)
Summary sheet contains the following: religious preference,
(a)The name, gender, date of birth, and previous address
religious preference, and previous X
address  The above required information was not consistently
found in the files reviewed.
Information about Children in Care 413-215-0396 (1)
Summary sheet contains the following: (b) Name and
location of previous and current school
(b) Name and location of previous and
X
current school
 The above required information was not consistently
found in the files reviewed.
(c) Date of admission X
(d) Legal custody X
(e) The name, address, and telephone X
number of:
(A) The child's parents.
47
(B) The child's legal guardian, if
different than parents, and legal
relationship
(C) Other persons significant to child
(D) Other professionals to be involved
in service planning (if applicable)
(f) Required consents and authorizations X
Health Services Corrective Action
Yes No N/A Corrective Action
413-215-0376 Completed
(2) Medical history obtained within 30 days X
(a) significant findings
(b) current immunizations, history of
surgical procedures-health issues-injuries
(c) allergies
(d) dental, vision, hearing, behavioral
health, and
(f) physician orders
(2)(e) Documentation of age appropriate X
instruction – pregnancy prevention,
nutrition, prevention of HIV & AIDS, and
prevention and treatment of sexually
transmitted disease
(3) Agency provides or arranges for X
(a) information on maintaining reproductive
health and birth control
(b) prenatal care
(c) well baby care
(d) fetal alcohol syndrome
(e) accessing health insurance
(f) cancer screenings
(g) feminine hygiene products
(h) access to birth control and vaccinations
(4)(a) to (f) Medical exams (3 in first year
of life, 2,4,6,9,14) X
Consents Corrective Action
Yes No N/A Corrective Action
413-215-0391(1) Completed
(a) Provide routine and emergency X
medical care
(b) Use the discipline and behavior X
management system
(c) Use restraint or seclusion (if X
applicable). Must specify the reasons for
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the intervention and how staff and proctor
foster home parents are trained and
supervised
(d) Restrict contact with persons outside of X
the agency
(e) Allow access as defined in 413-215- X
0091 & 0101
(f) Impose a dress code X
(g) Apply the reasonable and prudent X
parent standard
Disclosures
Corrective Action
413-215-0391(2) Parent/guardian has Yes No N/A Corrective Action
Completed
acknowledged in writing:
(a) Mandatory child abuse reporting X
requirements
(b) Information regarding personal or room X
searches and protocols for confiscation of
contraband
(c) Statement of Rights of Children and X
Parents/Guardians
(d) Grievance policies and procedures X
(e) Any policies and procedures upon X
request
Authorizations Corrective Action
Yes No N/A Corrective Action
413-215-0391(3) Completed
(a) Disclose information X
(b) Child specific visitors X
(c) Visitation resources are pre-approved X
(d) Activity specific authorizations are pre- X
approved to allow children to participate in
potentially hazardous activities, including
but not limited to using motorized yard
equipment, swimming, and horseback
riding.
Service Planning Corrective Action
Yes No N/A Corrective Action
413-215-0396(2) Completed
(a) All documentation written in terms that X
are easily understood
(b) Intake document is completed the date X
child accepted into care (emergency
placement 48 hours)
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(c) Child is served according to an X
individual service plan that outlines goals
for services and care coordination
(d) Assessment is completed within 30 X
days and contains relevant historical info.,
current behavioral observations, identified
need for services, and how agency will
provide or coordinate services
(e) (A)&(B) Service plan within 60 days X
(parent, guardian and child actively
involved). Describes how child’s issues will
be addressed, anticipated outcomes and
reviewed by child and guardian/parent.
(e)(C)&(D) Service plan is reviewed X
quarterly and revised when information
indicates other services should be
provided
Case Management Corrective Action
Yes No N/A Corrective Action
413-215-0396(3) Completed
(a) Services are documented, progress X
toward achieving goals is tracked
(b)-(d) discharge planning and instructions X
(e) Follow-up services identified (if X
applicable)
(f) Incident Reports X
Financial Records Corrective Action
Yes No N/A Corrective Action
413-215-0396(4) Completed
Records contain (if applicable)
(a) date, amount,
(b) source X
(c) purpose
(d)&(e) signatures
Personal Possessions Records Corrective Action
Yes No N/A Corrective Action
413-215-0396(5) Completed
Individual written inventory of all personal
possessions is maintained and updated as X
needed
Records and Documentation Corrective Action
Yes No N/A Corrective Action
413-215-0071 Completed
(1) Stored safely X
(2) Permanent, legible, dated, and signed X
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(7) Permanent registry for each child in X
care includes (name, gender, birth date,
names, addresses of parents or guardians,
dates of admission, and placement upon
discharge)
Corrective Action for Documents Required at a Licensing Review
 The following Policy’s require revisions to meet the Licensing Rules:
The Discipline, Behavior Management and Suicide Prevention Policies at all programs need to be revised to align with the
following rule:
413-215-0076 Licensing Umbrella Rules: Discipline, Behavior Management, and Suicide Prevention (1) A child-caring agency,
except a child-caring agency licensed only to provide adoption services under OAR 413-215-0401 to 413-215-0481, must adopt
and adhere to written policies and procedures on discipline, behavior management, and suicide prevention that meet all of
the requirements of this rule. (b) The discipline and behavior management policies and procedures must prohibit the
following: Spanking, hitting, or striking with an instrument. (B) Committing an act designed to humiliate, ridicule, or degrade a
child in care or undermine the self-respect of a child in care. (C) Punishing a child in care in the presence of a group or
punishment of a group for the behavior of one child in care. (D) Depriving a child in care of food, clothing, shelter, bedding,
rest, sleep, toilet access, or parental contact. (E) Assigning extremely strenuous exercise or work or requiring a child in care
to spend prolonged time in one position likely to produce unreasonable discomfort. (F) Using physical restraint (see
paragraph (3)(d)(A) of this rule) or seclusion as discipline. (G) Permitting or directing a child in care to punish another child in
care. (H) Using any other kind of harsh punishment. (I) Denying a parent, guardian, or sibling the right to visit or communicate
with a child in care solely as a disciplinary measure against the child in care. (J) Aversive conditions, which includes, but is
not limited to, any technique designed to or likely to cause a child physical pain, the application of startling stimuli, and the
release of noxious stimuli or toxic sprays, mists, or substances in proximity to the child in care.
 All the program policies were missing the following information.
413-215-0056 Licensing Umbrella Rules: Policies and Procedures (2) In addition to other policies and procedures required by
these rules, the policies and procedures in section (1) of this rule must include: (a) A written policy on mandatory child abuse
reporting, consistent with ORS 418.257, 418.258, 419B.005, 419B.010, and 419B.015 that includes requirements that child-
caring agency employees, staff, contractors, agents, and proctor foster parents do all of the following: (A) Immediately report
suspected child abuse directly to the Department via the child abuse reporting hotline. (B) Receive child-caring agency-
provided training on mandatory abuse reporting requirements as part of employee orientation and at least annually thereafter
as described in OAR 413-215-0061. (C) Receive child-caring agency-provided training on the definitions of child abuse in ORS
418.257 and 419B.005 that apply in child-caring agencies.
 The above required information was missing in the agencies Mandatory Abuse Reporting Policy.
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o 4.10 Preventing, Detecting and Responding to Sexual Abuse and Harassment Procedure. The procedure does not
require the mandatory reporter immediately making the child abuse report to the Child Abuse Hotline, but instead
directs staff to contact management. Licensing must be notified when the child abuse hotline is contacted, which
should be called when any abuse that is suspected and or disclosed occurred anywhere in the US or other countries.
The program’s policy must require reporting when abuse is alleged to have occurred while children were in the care or
custody of Department of Homeland Security or any other government agency 5.8.4
 The policy didn’t reflect the training requirements described in Licensing rules and didn’t include the statutory definition of abuse.
 The agencies Ethics and Standard of conduct document stated, “State law requires some Morrison Employees to immediately
report any knowledge of physical, sexual Abuse of neglect. Any employee with knowledge or evidence should consult their
supervisor or other appropriate program authority as soon as possible. This must be changed as Morrison is a child-caring
agency, and all employees and volunteers are Mandatory Reporters. As previously noted, the policy must be clear in its
requirement for employees and volunteers to report abuse directly to the DHS Child Abuse Hotline, as opposed to reporting
abuse to management. The policy can require reporting to other parties in addition to the Hotline, but mandatory reporters have
a personal and individual responsibility to report suspected abuse to the Hotline.
413-215-0046 Licensing Umbrella Rules: Children and Families Rights Policy and Grievance Procedures (2) Grievance
Procedures. The procedures must include all of the following: (D) The name, address, and phone number of: (i) A Department
licensing coordinator; and (ii) Any other governmental entities with oversight responsibilities.
 The Grievance Policy for all programs was missing the above required information.
Sage:
The program policies were missing the following information:
413-215-0076 Licensing Umbrella Rules: Discipline, Behavior Management, and Suicide Prevention (3) Behavior Management.
(D) Any use of physical restraint by a staff member or proctor foster parent of the child-caring agency, if the member is not
trained in a nationally recognized nonviolent crisis intervention system, must also be reported to a Department licensing
coordinator within one working day of occurrence. (E) Limitations. The child-caring agency must have a policy that prohibits
the application of a nonviolent physical restraint to a child in care who has a documented physical condition that would
contraindicate the use of that particular restraint, unless a qualified medical professional has previously and specifically
authorized its use in writing for that child in care. Documentation of the authorization must be maintained in the child in care's
record.
(F) Physical Restraint Documentation. The policies of the child-caring agency must require a report on an incident report form
of behavior that required the use of physical restraint. The report must include ……..the length of time the physical restraint
was applied (SAGE). The report must include the time the restraint started and the time it was terminated, the debriefing
completed with the staff and child in care involved in the physical restraint, and documentation of a review by the executive
director, program director, or designee. (G) Review. The policies of the child-caring agency must require that whenever a
physical restraint is used on a child in care more than two times in seven days, there is a review by the executive director, the
52
director's designee, or a management team to determine the suitability of the program for the child in care, whether
modifications to the child in care's plan are warranted, and whether staff need additional training in alternative therapeutic
behavior management techniques. The child-caring agency must take appropriate action indicated by the review.
 SAGE’s Behavior and Restraint Policy was missing the above required information.
413-215-0046 Licensing Umbrella Rules: Children and Families Rights Policy and Grievance Procedures (Amended 1/1/19) (1)
Rights of children in care and families served by the child-caring agency. A child-caring agency must guarantee the rights of
children in care and the families the child-caring agency serves. A child-caring agency must enact and adhere to a policy
ensuring those rights. A written copy must be distributed to all children in care and families served by the child-caring
agency, and afford the following rights: (a) Except as provided in paragraph (B) of this subsection, the child in care's right to
uncensored communication with legal guardians, caseworkers, legal representatives, and other persons approved for
communication by the legal guardian or as provided in a court order. (A) This right cannot be waived, including voluntarily.
Restriction on communication between a child in care and his or her legal guardian may not be a condition of participation in
the program.
 SAGE, ORR Programs, Breakthrough and Counterpoint were missing the above required information in their Child Rights
Policies.
(B) A child-caring agency may place reasonable limits on communication, but only as provided in the child-caring agency's
policy. Reasonable limits include, but are not limited to, having set time periods during the day for visitation and phone calls
and imposing moderate limits on the duration of calls or visits. However, a limitation is not considered reasonable if it
prevents the ability to meaningfully communicate, such as not allowing contact with a child in care's attorney during regular
business hours.
 SAGE, ORR Programs, Breakthrough and Counterpoint, and TFC and respite were missing the above required information in
their Child Rights Policies.
(f) The child in care's right to have adequate and personally exclusive clothing.
 SAGE, ORR Programs, Breakthrough and Counterpoint, TFC and Respite did not specifically state the entire verbiage from the
rule “adequate and personally exclusive clothing” in their policies. The policies did state they were to have their own clothing.
(j) The child in care's right to have timely access to physical and behavioral health care services. (SAGE)
 SAGE was missing the above required information in their Child Right policy.
PASO:
413-215-0076 Licensing Umbrella Rules: Discipline, Behavior Management, and Suicide Prevention (1) A child-caring agency,
except a child-caring agency licensed only to provide adoption services under OAR 413-215-0401 to 413-215-0481, must adopt
53
and adhere to written policies and procedures on discipline, behavior management, and suicide prevention that meet all of
the requirements of this rule. (3) Behavior Management. (E) Limitations. The child-caring agency must have a policy that
prohibits the application of a nonviolent physical restraint to a child in care who has a documented physical condition that
would contraindicate the use of that particular restraint, unless a qualified medical professional has previously and
specifically authorized its use in writing for that child in care. Documentation of the authorization must be maintained in the
child in care's record.
(F) Physical Restraint Documentation….. the debriefing completed with the staff and child in care involved in the physical
restraint, and documentation of a review by the executive director, program director, or designee. (G) Review. The child-
caring agency must take appropriate action indicated by the review.
 Paso’s Behavior and Restraint Policy was missing the above required information.
Downtown Shelter:
413-215-0076 Licensing Umbrella Rules: Discipline, Behavior Management, and Suicide Prevention (E) Limitations. The child-
caring agency must have a policy that prohibits the application of a nonviolent physical restraint to a child in care who has a
documented physical condition that would contraindicate the use of that particular restraint, unless a qualified medical
professional has previously and specifically authorized its use in writing for that child in care. Documentation of the
authorization must be maintained in the child in care's record. (F) Physical Restraint Documentation….. the debriefing
completed with the staff and child in care involved in the physical restraint, and documentation of a review by the executive
director, program director, or designee. (G) Review. The child-caring agency must take appropriate action indicated by the
review.
 The Downtown Shelter Behavior and Restraint Policy was missing the above required information.
Group Home:
413-215-0076 Licensing Umbrella Rules: Discipline, Behavior Management, and Suicide Prevention (3) Behavior
Management. (E) Limitations. The child-caring agency must have a policy that prohibits the application of a nonviolent
physical restraint to a child in care who has a documented physical condition that would contraindicate the use of that
particular restraint, unless a qualified medical professional has previously and specifically authorized its use in writing for
that child in care. Documentation of the authorization must be maintained in the child in care's record.
(F) Physical Restraint Documentation….. the debriefing completed with the staff and child in care involved in the physical
restraint, and documentation of a review by the executive director, program director, or designee. (G) Review. The child-
caring agency must take appropriate action indicated by the review.
 The Group Home Behavior and Restraint Policy was missing the above required information.
Break Through and Counterpoint:
54
413-215-0076 Licensing Umbrella Rules: Discipline, Behavior Management, and Suicide Prevention (3) Behavior Management
(c) Time Out. (C) Rooms used for "time out" must have adequate space, temperature, light, and ventilation. (D) "Time out"
episodes must be documented in the child in care's record.
 Breakthrough and Counterpoint’s Behavior and Restraint Policy was missing the above required information.
5-25-2021
Licensing Coordinator’s Signature: ________________________ Date: ___________________
Manager Review: ______________________________________ Date: ____5__-1__1_-_2_0_2_1_ ____
55

agency_name: Morrison Child and Family Services (MCFS)

program_type: (DT) Day Treatment Programs | (FC) Foster Care Programs | (RC) Residential Care Programs

view_code: RC

visit_date: March 29 through April 5, 2021

licensing_coordinator: Holly Ivey, Tom Heidt, and Irvin Minten

program_compliance:
The program is or will be compliant with OAR 413-215-0001 through 0131 Licensing Umbrella Rules, OAR 413-215-0301
through 0396 Licensing Foster Care Agencies, OAR 413-215-0501 through 0586 Licensing Residential Care and OAR 413-215-0801 through 0856
Licensing Day Treatment.
Personnel records were reviewed and compliance with required background checks was documented for employees in all programs.
Agency Description(s):
Morrison Child and Family Services was founded in 1947, by Carl V. Morrison, who was a psychologist in Portland. It has grown to be a large
organization, with a projected annual budget of around 30 million, and they employ approximately 405 staff. Morrison Family Services served 7,935
children and families in 2019-2020. Morrison has programs that are licensed by DHS Licensing and outpatient programs that are not.
Individual Program Description(s):
Planned and Crisis Respite- Provides planned or emergency short-term overnight respite services for children 3-17 years old. Respite providers
are certified Therapeutic Foster Parents through Morrison. The providers have been screened and specially trained to work with children and youth
who have a history of mental illness and may have been impacted by trauma. Respite homes provide a safe, supportive and structured
environment in which youth can take advantage of new opportunities. The average length of stay in 2020 was 2 days and the service is primarily
utilized on weekends. At the Licensing Review it was reported there were 15 certified foster homes, with a capacity to serve 34 children.
Therapeutic Foster Care-
Morrison's Therapeutic Foster Care (TFC) program provides a safe and nurturing environment with care provided by specially screened parents
who are trained to work with children and youth impacted by trauma. TFC children and youth are 3-17 years old living in the Portland-Metropolitan
area and have been referred by their Child Welfare Caseworker for Therapeutic Foster Care because of clinical and behavioral issues that require
specialized care. Morrison's TFC program is contracted to provide care for up to 12 children. Often youth participating in TFC have experienced
multiple attachment disruptions and have suffered neglect as well as severe physical, sexual and emotional trauma. As a result, they can
experience mental health and behavioral issues that make it difficult for them to cope with daily routines and relationships. The average length of
stay in 2020 was 452 days. At the Licensing Review it was reported there were 4 certified foster homes, with a capacity of to serve 7 children.

Breakthrough Day Treatment - Breakthrough is an innovative day treatment program that combines substance use disorder treatment, skills
training, psychiatric services and alternative education. Day treatment is combined with proctor care to create 24 hour, 7 days/week therapeutic
environments for youth served. The day treatment program is open 8:45am to 4 p.m. Monday-Friday and proctor homes provide care, support and
supervision during evenings and weekends. Day treatment programming includes a variety of individual, group and family treatment and an on-site
accredited classroom provided by Portland Public Schools. The primary method of treatment is group counseling aimed at helping youth with social
behaviors, substance use problems and other key issues, such as anger management, family relationships and decision making. Health care
monitoring and follow-up services are also provided. The school and treatment components are interwoven throughout the program day and
include recreational activities and a meal service for youth placed in the program. The program utilizes Cognitive Behavioral Therapy, Motivational
Interviewing and a variety of other evidence-based practices that have proven successful for treatment of delinquency and substance abuse. Youth
receive an intensive program modeled on positive peer culture and responsibility to others. Youth referred to the Program are 12-17 years old, have
substance use problems, are usually involved with the juvenile justice system and have often been unsuccessful in other treatment settings.
Referrals for day treatment are taken from multiple sources such as DHS, schools and parents or family members. The combined day treatment
and proctor home program only accepts referrals from the Oregon Youth Authority.
Breakthrough Foster Care - Proctor parents are recruited and trained by Breakthrough Staff and are certified through the Oregon Youth Authority.
Breakthrough staff provide intensive training, support, and coaching to assist proctor parents in responding to key social, emotional, and behavioral
concerns that youth have. Proctor parents receive monthly home visits, attend weekly training, and support groups, and receive daily
communication about the needs and behavior of youth in care. Proctor parents also receive individualized coaching when they request additional
support, when youth needs increase or change significantly, and when staff assess that increased supervision would be beneficial. Breakthrough
proctor parents are expected to develop therapeutic relationships with youth, provide safe, healthy home environments, and support 12-Step
Programs and recovery activities. At the time of the Licensing Review it was reported there were 4 certified homes with a capacity of 4 beds. The

average_length_of_stay: The average length of stay was identified by program managers. Planned Crisis Respite Foster Care: (Primarily this service is only utilized on weekends) - 2019- 2-3 days - 2020- 2 days Foster Care Program: - 2019- 700 days - 2020- 452 days Breakthrough: - 2019- 164 days - 2020- 104 days Counterpoint: - 2019- 459 days - 2020 374 days Paso: - 2019- 76 days - 2020- 47 days 5 SAGE: - 2019 305 days - 2020 268 days Residential Care Program Update-Long Term Group Home: - 2019- 196 days - 2020- 175 days Residential Care Program Update-Shelter: - 2019- 61 days - 2020- 46 days

average_daily_population_served: The average daily population was identified by program managers. Planned Crisis Respite Foster Care: - 2019- 52 children - 2020- 39 children Foster Care Program: - 2019-5 children - 2020- 4 children Breakthrough: - 2019- 4 children - 2020-1 children Counterpoint: - 2019-9 children - 2020- 6 children Paso: - 2019- 9 children - 2020- 2 children SAGE: - 2019-11 children - 2020- 9 children Residential Care Program Update-Long Term Group Home: - 2019-11 children - 2020-26 children 6 Residential Care Program Update-Shelter: - 2019-38 children - 2020- 16 children

number_of_children_served_annually: Number of children served was identified by program managers. Planned Crisis Respite Foster Care: - 2019- 191 children - 2020-143 children Foster Care Program: - 2019-8 children - 2020-11 children Breakthrough: - 2019-19 children - 2020-17 children Counterpoint: - 2019- 16 children - 2020- 19 children Paso: - 2019-52 children - 2020- 19 children SAGE: - 2019-30 children - 2020- 30 children Residential Care Program Update-Long Term Group Home: - 2019-28 children - 2020- 26 children Residential Care Program Update-Shelter: - 2019- 276 children - 2020-154 children

use_of_seclusion_or_restraint: Morrison programs prohibit seclusion. Staff at the following programs are trained in Non-violent Crisis Intervention (NCI) as restraints are allowed in emergency situations. Paso, The Downtown Long-Term Group Home and Shelter, The Foster Care Programs to 7 include foster parents. SAGE Staff are trained in the Mandt Intervention System. Counterpoint and Breakthrough Day Treatment are "hands off" programs. The staff are trained in NCI's non-physical interventions and de-escalation techniques.

interviews_observations:
At the Licensing Review nine staff members, two foster parents and eleven children were interviewed. The following
information was gained during the interviews with the children:
- Many children reported appreciating the staff.
- The children all reported being able to talk to people on their approved contact list.
- All the children reported being provided enough food to eat, to include receiving daily snacks.
- The children all reported their hygiene needs were being met by the program.
- All the children reported feeling safe at the programs where they were residing, to include foster homes.
There were no concerns that were identified during the interviews with staff, foster parents or children. While conducting the onsite inspection at the
programs children and staff were observed. The children that were observed appeared to be at ease and comfortable while residing in the
programs. The facilities were observed to be well maintained, with minimal repair needs.

program_strengths:
The following strengths were identified by Licensing Staff:
- Files were consistent and well organized across all programs. Files included multiple tabs that clearly marked each section.
- Across all programs it appeared staff were committed to the care of the children served.
- Staff are well qualified for their positions.
- The children in the program are receiving evidence-based treatment to meet their complex needs.
Individual program strengths identified by program managers.
- Planned Crisis Respite Foster Care:
o "A significant program strength is the willingness of existing respite providers to provide services in their homes during the COVID-19
pandemic. They have adapted very flexibly to following extensive infection control guidelines.
o Another strength of the program lies in the quality of the respite staff. They demonstrate keen abilities in coordinating care and services
and providing extensive after-hours supports. Both respite providers and staff are committed to supporting children and youth and
promoting their healthy development by preventing unnecessary disruptions in the relationships that they have with others."
- Foster Care Program:
o "Therapeutic Foster Care (TFC) provides a safe and nurturing care-giving environment provided by parents who are specially trained and
screened to work with children impacted by trauma. The program provides intensive case management, skills training and 24-hour crisis
response to support children and youth in meeting individualized treatment goals and placement stabilization.
8
o The TFC Program increased the number of youth served during 2019 from an average of 4 youth to an average of 8 youth. One youth is
stepping over to DHS care and remaining in their long-term placement and two youth have successfully reunified with their biological
parent.
o The program has strong collaboration with Morrison's Planned and Crisis Respite program to provide much needed relief for the TFC
families.
o Foster home recruitment and retention continues to prove challenging during the COVID-19 pandemic. However, efforts with the Foster
Plus Collaborative and Morrison's recent implementation of an advertising campaign has improved exposure and increased the pool of
interested resource families. TFC has hired new case managers and a Program Supervisor to sustain the program.
o TFC has begun implementation of the Attachment, Regulation and Competency (ARC) model with clients and the ARC Reflections
curriculum for foster parents."
- Breakthrough and Counterpoint:
o "Many Counterpoint Day Treatment program youth make significant academic progress while in the Program, gaining high school
credits and advancing grade levels more quickly than in the past.
o Program youth have a very low juvenile justice recidivism rate.
o Program youth have opportunities to engage in cultural and recreational activities that they may not have had before.
o The Counterpoint Day Treatment and Proctor Care Program has a stable group of experienced proctor homes, ranging from 5-10
years longevity with Counterpoint."
- Paso:
o "According to the Office of Refugee and Resettlement, the Morrison PASO program is a Staff Secure program. It is one of only 5
Staff Secure programs in the nation and has been operating for 10 years with many experienced staff.
o PASO has adapted programmatically to respond to the increasing mental health needs of the youth served in the program. PASO
has developed a wide variety of mental health services, recreational services and a robust calendar of engaging activities for the
youth served.
o The program has benefitted from many facility improvements and renovations this year and has a fresh, new, inviting and youth-
friendly environment and atmosphere.
o PASO staff are a strength of the program. They are currently participating in Dialectical Behavioral Therapy (DBT) training with the
goal of becoming certified in this evidence-based approach. They use a wide range of therapeutic interventions to meet the
individual needs of youth who come into the PASO program. In addition, most staff are bilingual/bi-cultural and all have a strong
passion for serving the youth at PASO.
o Youth report satisfaction with the program, and that they feel supported by the program."
- SAGE:
o "SAGE (Strength, Achievement, Growth, and Empowerment) is trauma informed and strengths based. Treatment is youth centered and
youth driven.
9
o SAGE Staff are provided ongoing training opportunities specific to work with trauma survivors. The program is able to address multiple
client needs simultaneously, including safety, which would be difficult to do in a less restrictive setting.
o The program offers individualized educational opportunities with credit recovery options to re-engage youth in education. Individual art
and music lessons are offered per youth request. SAGE offers vocational training opportunities for youth who may be entering the
workforce upon discharge, and we collaborate with community partners to create effective systems of support for youth while they're in
the program and when they return to the community."
- Residential Care Program Update-Long Term Group Home:
o 'Youth report that they are satisfied with services and feel supported by the program.
o The program has a successful partnership with Lincoln High School, where the youth attend school. Youth have the support of
program staff to meet academic and other school-related goals.
o Staff bring unique creativity to the task of decorating and outfitting the program facility; the environment creates an atmosphere of
support and comfort for the youth.
o Individualized skill building, independent living skills training and acculturation activities are provided for the youth. The youth have
access to a wealth of local resources for educational and recreational opportunities.
o Collaborative Problem Solving is utilized to respond to youth behavior.
o The Program has benefitted from experienced leadership (Program Director, Assistant Program Director) and case management
staff.
o Youth have successfully entered the State of Oregon foster care system from the program.
o The program implemented the Child and Youth Care Certification Model, with the goal of increasing staff skills, competency and
retention. The Long-Term Group Home implemented a child and youth care worker certification program and have encouraged
Milieu Counselors to become certified.
o The Child and Youth Care Certification Board Model (CYCCB). The CYCCB model provides an assessment and training process
that leads to national certification. Staff competencies are organized across five domains: professionalism, cultural and human
diversity, applied human development, relationships and communication and developmental practice methods."
- Residential Care Program Update-Shelter:
o "Youth served reported overall satisfaction with the program and that they received support from the program during their stay.
o Increased staff training has occurred at the Downtown Shelter since the last licensing renewal. Training has included the following:
Child and Youth Care Certification Board (CCYCB) recommended trainings for youth care workers, Nonviolent Crisis Intervention,
Columbia Suicide Severity Rating Scale Screening, Collaborative Problem Solving (CPS) and the trauma-informed Sanctuary Model.
Milieu Counselors are working towards Child and Youth Care Worker certification. Sanctuary Model training has helped reduce staff
burnout and increase morale. Creating opportunities for staff to participate in brief in-service trainings, "Sanctuary Snacks", allows
time for reflection and team building. With the goals of increasing professional competency and skills and retaining direct service
staff, the Downtown Shelter program began the implementation of the Child and Youth Care Certification Board (CYCCB) model
during the past year. The CYCCB model provides an assessment and training process based upon five domains of study and
practice: professionalism, cultural and human diversity, applied human development, relationships and communication, and
developmental practice methods.
10
o Staff have been cross-trained in different areas allowing for back-up coverage and consistent program operations when there is a
fast-paced work environment and staff turnover.
o The Downtown Shelter has created a welcoming environment for youth by integrating more culturally appropriate resources in the
school program, recreational activities, food service, community groups, and mental health referrals. Recreational spaces for youth
such as the second-floor gym and activity rooms have allowed youth to find a safe and healthy method for calming and self-soothing
activities. Youth have benefited from recreational activities such as yoga, soccer coaching, educational outings, gardening classes,
and talent shows.
o Only one Downtown Shelter youth was recommended for a higher level of care during the past year."

program_challenges:
Individual challenges identified by program managers.
- Planned Crisis Respite Foster Care:
o "Morrison respite services faced multiple challenges during the past two years - difficulties in engaging, recruiting, and maintaining
respite providers during the COVID-19 pandemic and financial instability when specialized funding ended. Morrison made the difficult
decision to close our Mid-Valley Respite program when pilot funding ended December 31, 2019. The number of homes that had
been recruited, and the volume of respite care provided, did not support the cost of the program.
o An on-going challenge is having enough respite beds to meet the needs of the populations and communities served."
- Foster Care Program:
o "TFC has experienced a high rate of changes as a program over several years, including closure of the Knott site, program re-
location and significant leadership changes. These transitions have led to difficulty in stabilizing the TFC program, including a high
turnover rate among staff into the 2018-2019 fiscal year. However, significant efforts are underway to stabilize the program including
hiring a Division Director, filling vacant Case Manager positions and hiring a Program Supervisor. Plans are underway to hire a
therapist for the team as well.
o Recruitment of skilled foster parents has remained a challenge over the last few years. Changes in reporting requirements, negative
press about foster care and fears about allegations have led to a difficulty maintaining a pool of qualified foster parents. Morrison
continues to participate in Foster Plus to help with recruitment efforts, and significant improvements to our program are underway. In
addition, increases in daily rates to support appropriate staffing, recruitment efforts and increased payments to foster parents are
helping to buffer the difficulties.
o Ongoing effort to match children/youth to an appropriate foster placement occurs; yet, there are no full proof methods for ensuring
placements will not disrupt. Unplanned discharges occurred more than expected and has led to a decline in number of youth served
at present, even with the increase of client enrollments during 2019-2020. One unplanned client discharge was directly related to
COVID-19/shelter-in-place order.
o A few TFC providers have opted to move to only provide respite care or moved to proctor care with another Morrison program, which
has recently reduced TFC's capacity"
11
- Breakthrough and Counterpoint:
o "Proctor home recruitment and retention is a significant challenge. Breakthrough requires specially trained, attentive, and available
parents that are willing to be involved in the program's daily operations. Currently, most day treatment services and proctor care is
suspended due to a lack of foster homes; capacity is 0. New proctor parent recruitment and certification is underway. We expect to
have 3 new proctor homes certified by the end of 2020.
o Due to limited funding, the Program no longer has a Proctor Manager and other staff have had to pick up these responsibilities.
o Youth referred to Breakthrough during the past two years have more acute health, mental health and SUD treatment needs and there
are limitations to what the juvenile court system can do to address these needs.
o Counterpoint requires specially trained, attentive, and available parents that are willing to be involved in the program's daily
operations. Recruitment of foster homes is a challenge as many are hesitant to provide care for this specialized service.
o Currently, day treatment therapists need to have specialized training and supervision and be certified through the State of Oregon
Sexual Offending Treatment Board, but OYA and other funders do not recognize this expense. The Oregon Youth Authority contract
pays for services at BRS rates that are lower than treatment rates. As a result, the Program provides sexual offense treatment but is
not fully reimbursed for all costs.
o The impacts of the COVID-19 pandemic continue to be challenging for the Program. The emergency shut down and stay at home
orders resulted in CPDT program staff assuming the responsibilities of supervising and supporting educational services during the
spring and summer of 2020 and into the new school year. Educational services have been provided on-site without the support of
Portland Public Schools staff. Currently, youth are attending school via video conferencing at the CDPT site and Morrison staff
continue the role of supervising the school sessions.
o The emergency shut down also created a gap in CPDT food services. Our vendor stopped providing and delivering lunch to the
Program. This need was met through CPDT staff picking up daily free sack lunches provided by the School District.
o The impact of the COVID-19 pandemic has been challenging. Breakthrough staff have continued to provide education supports and
services without the PPS school staff onsite for the spring and summer of 2020 and into the new school year. Currently, the youth
are attending school via video conferencing at Breakthrough, and Morrison staff have taken on the role of supervising the school
sessions. Emergency shutdowns and stay-at-home orders also created a gap in Breakthrough food services as the vendor was no
longer able to cook and deliver lunch to the program. This need was met via daily pick up of free sack lunches offered by the school
district."
- Paso:
o "During the past two years, the program has faced challenges due to level of care concerns and dilemmas. Many youth placed at
PASO by the Office of Refugee and Resettlement (ORR) have needed a higher level of care due to very serious mental health and/or
behavioral concerns. The populations referred seemed to need behavioral health residential treatment setting or highly secure,
locked settings that were unavailable. The PASO program has had to navigate these challenges by adapting the program to meet
the needs of individual youth or advocating for admission to a higher level of care. Simultaneously, ORR-funded programs like
PASO have been under pressure to respond to ORR policy mandates that require programs to transfer youth to a lower level of care
with specific timeframes. The challenge is that sometimes the youth are not ready for that quick transfer to a lower level of care, but
Federal policy requires it and does not take into full consideration each youth's individual needs.
12
o During the past year several youth in the program had aggressive outbursts and engaged in significant property damage. The
program has had to recover from property damage, and staff have had to recover from the traumatic experience of being involved in
these events.
o Staffing the program is challenging. Front-line milieu counselor positions require experience working with children and Spanish-
language proficiency (preferred) that is hard to acquire. The federal Office of Refugee and Resettlement requires an extensive
background check and fingerprinting that must be completed prior to employment. There are no allowances for preliminary
clearance. This process may take from 1-3 months depending on individual circumstances and the States in which they've
applicants have lived.
o COVID-19 has greatly affected the program by way of reduced referrals, changes in immigration policy, staffing concerns and limited
resources."
- SAGE:
o "Limited capacity and length of stay has compounded the number of youth that are unable to access the program.
o Engagement is challenging for families that live out of County, and there exits a lack of appropriate resources and/or placement
options for youth transitioning out of care for this specific population of youth."
- Residential Care Program Update-Long Term Group Home:
o "The Program faces difficulty in filling open direct service positions and encounters challenges with both recruitment and staff
retention.
o Food continues to be a challenge for the program. Serving youth from all over the world creates competing desires and preferences
about what kind of food is served. The Program is working with Morrison's kitchen team to provide a variety of foods for the youth.
o Some youth decline a large amount of program services that they could benefit from."
- Residential Care Program Update-Shelter:
o "Throughout the past two years Morrison has experienced significant challenges and delays in the process of hiring staff for the
Downtown Shelter program. Challenges have occurred in the following areas: recruiting and hiring direct service and management
staff with the qualifications necessary for the vacant positions, recruiting and hiring bi-lingual, Spanish-speaking staff including
management and clinical staff, and complying with new federal mandates to thoroughly screen job applicants and their criminal
backgrounds prior to hire. These processes have been time-consuming and full of delays making it challenging to maintain youth
supervision and coverage of all program operations. Staff resignations and staff turnover have put pressure on service delivery and
program operations. The Program Director position has been vacant for 1 ½ years, although Morrison was recently able to promote
the Assistant Program Director to the Program Director position.
o The COVID-19 pandemic has impacted youth and their length of stay in the program, creating delays in discharge and reductions in
referrals. Operational changes and CDC-recommended safety precautions have been implemented to respond prudently and safely
to COVID-19 i.e. screening individuals as they enter the building, marking spots for social distancing, required mask wearing,
frequent sanitizing, creating procedures and the physical space for quarantines and reducing the overall number of people in the
building. Staff concerns include feeling unsafe and that they do not want to put themselves or family members at risk.
13
o Increased media attention related to immigrant youth in 2019 and social unrest in downtown Portland near our facility in 2020 has
created anxiety for youth and staff."

changes_in_last_two_years:
Individual program changes in the last two years identified by program managers.
- Planned Crisis Respite Foster Care:
o "Foster home recruitment and retention in the Portland metropolitan area continues to prove challenging, however efforts to
collaborate with the Foster Plus Collaborative and Morrison's recent implementation of an advertising campaign, including social
media ads, have increased the pool of interested resource families.
o The numbers of children and youth have steadily declined in the past fiscal year (FY 21) due to the impact of COVID-19 and the
need to impose restrictions. Prior to the COVID-19 Pandemic the program was providing respite care to approximately 160 unique
children/youth with a total of 1549 nights. The Mid-Valley PCRC successfully recruited 10 respite homes and served approximately
55 during the two years that it was open. After struggling with start-up and funding problems, the program closed in March, 2020. To
be sustainable in the region the program needed to increase the amount of services provided and the number of homes. Additional
community development and start-up time was also needed."
- Foster Care Program:
o "TFC as a program has had significant changes in the last two years. TFC moved to a new facility that is not as conducive to child
activities and has had a high rate of staff turnover. The program/agency has been resourceful to find Morrison locations that meet the
needs when changes occur and is in the process of building the Rotary Youth Center to support a child and family friendly
environment (construction should be complete in November this year).
o There have been some positive changes in staffing with the addition of a Division Director who has brought clinical insight and vision
to the program. The decision has been made to incorporate a licensed therapist to the team, along with implementation of the ARC
model to address and improve upon the Attachment, Regulation and Competency skills TFC is working to support for the clients and
their families. The addition of a Program Supervisor position has helped to strengthen support to the Case Managers. Other staff
changes occurred in our recruitment and certification team. A new recruiter/trainer was hired in April 2020, which was a vacant
position for 4 months, and before that in October 2019 a new certifier was hired. We feel confident that our program is stabilizing and
that we will continue to grow and refine ourselves in order to more effectively serve children and families."
- Breakthrough and Counterpoint:
Breakthrough-
o "Construction was completed recently on a new recreation building located at next to the Morrison Sandy Boulevard building. Called
the Rotary Youth Center, it is sponsored and partially funded by the Rotary Club of Portland. It will provide additional indoor,
recreational space for youth to gather, socialize and exercise. It is also designed for open air activities on the patio and garden areas.
14
The new building is considered additional program space for the Breakthrough and Counterpoint Day Treatment and Proctor Care
program.
o The elimination of the proctor manager position created a need to re-organize how we recruit, train and supervise proctor families.
Recently, Breakthrough entered a partnership with Youth Progress to assist in recruitment of Breakthrough homes. We have three
(3) homes currently in the training and certification process and hope to take new referrals in November.
o Breakthrough has developed an Outpatient SUD treatment component and is able to accept SUD outpatient youth and families as
clients in addition to day treatment youth and families."
Counterpoint-
o "The elimination of the proctor manager position created a need to re-organize how we recruit, train, and supervise proctor families.
Recently, the Morrison Breakthrough and Counterpoint programs entered a partnership with Youth Progress to assist in the
recruitment of new proctor care providers. We hope to achieve a small increase in the number of CPDT homes, perhaps by 1 or 2."
- Paso:
o "A Behavior Support Specialist position was created to provide more therapeutic support for youth; this position is supervised by the
Clinical Supervisor.
o The program has undergone many facility improvements and renovations this year and has a fresh, new, inviting and youth-friendly
environment. Renovations include: New flooring in the entire building, new paint, murals throughout the building, new showers, new
anti-ligature furniture, new classroom design, new lighting on outside of building, office updates, door updates, window repairs and
updates, and internal wall improvements. Other renovations included: bathroom remodeling, living room remodeling (cabinets and
removal of fireplace), garden re-design and new external siding.
o PASO revamped its behavior management policy and updated behavioral management protocols to include more therapeutic
interventions drawn from the evidence-based, trauma informed Sanctuary Model.
o PASO created and implemented new, interdisciplinary Youth Support Teams to provide a multi-disciplinary plan that will support
youth in achieving reunification or transferring to a level of care that meets their needs.
o PASO revised its group curriculums and has implemented Power Source, Aggression Replacement Therapy groups, and Life Skills
groups on a weekly basis.
o A new Assistant Program Director was recently hired with six years of experience at Morrison including ORR programming."
- SAGE:
o "Addition to the SAGE (Strength, Achievement, Growth, and Empowerment) program is a 4-bed program wing focused on safe and
supported community transition.
o Online educational program focused on credit recovery for credit deficient students is also a part of the program.
o An additional component which offers individual music, art, and language lessons as requested by clients."
- Residential Care Program Update-Long Term Group Home:
15
o "Significant change occurred in leadership roles. While skilled staff, both the Program Director and the Assistant Program Director are
fairly new in their roles.
o The COVID-19 Pandemic has created the following program and operational challenges:
o Youth are no longer attending school in person
o Staffing challenges and concerns
o Limited community activities"
- Residential Care Program Update-Shelter:
o "Program enhancements included the addition of specialized positions to strengthen quality and improve compliance. The
new positions are: a Medical Services Supervisor, Overnight Milieu Supervisor, Residential Security Specialist (RSS), and
Kitchen Supervisor. Leadership positions (Program Director and Assistant Program Director) were recently filled.
o Quick and immediate implementation of infection control procedures that were required and recommended by local, state,
and federal authorities to control the spread of COVID-19. The Shelter has remained open to serve youth, at times only a
few, during the Pandemic."

lawsuits:
The Program Manager of PASO stated the following regarding a lawsuit, "Yes.: Lucas R., et al v. Azar, et al.
All Federal Staff Secure Programs in the U.S. were party to a lawsuit brought against the HHS Secretary Alex Azar. This was not specific to
Morrison. Our PASO staff secure program was included with all other ORR staff secure programs in the subpoena, and therefore Morrison was
required to respond. Of note, the lawsuit had nothing to do with the care that youth were receiving in ORR facilities. Morrison paid legal fees and
was reimbursed by the federal Office of Refugee and Resettlement. "

exceptions:
Yes, an exception was requested by Morrison for the windows of the residential facilities. The exception was for the following DHS
Licensing Rule: Room and Space Requirements Bedrooms 413-215-0516(3) (c) Outside room with window allowing egress from building
- Prior to the Licensing Renewal Process the agency submitted an exception request for the residential programs, as the windows do not allow egress. The
exception was approved until the next Licensing Renewal. Nothing further is required of Morrison regarding this rule.

excerpt:
&(c) Buildings are
smoke free, clean and in good repair

excerpt:
(10) Written record of the administration
of medication includes:
(a) name
(b) description
(c) dates and times
(d) missed doses

excerpt:
Discipline and
Behavior Management

excerpt:
Designated staff
authorized to apply reasonable and
prudent parent standard are trained in
application of the standard

excerpt:
Mandatory reporting
(annually) that includes:
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter 106,
section 36
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee

excerpt:
(e) Allow access as defined in 413-215-
0091 & 0101

excerpt:
(a)The name, gender, date of birth,
religious preference, and previous address Information about Children in Care 413-215-0581(1)
Summary sheet contains the following: (a) religious
preference (b) Name and location of current and
previous school (e) The name, address, and
telephone number of: (C) Other persons significant to
child. (D) Other professionals to be involved in
service planning (if applicable)
 SAGE: The above required information (a,b,e,C,D).
was not consistently found in the files reviewed.
Religious preference was always left blank on the
form in the files reviewed.

excerpt:
(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

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.

excerpt:
(e)(C) &(D) Service plan is reviewed
quarterly and revised when information
indicates other services should be
provided

excerpt:
(a) Services are documented, progress
toward achieving goals is tracked Case Management 413-215-0581(3) (a) Services are
documented, progress toward achieving goals is tracked
(b)-(d) discharge planning and instructions
 Services: (SAGE) The above required information
was not consistently found in the files reviewed. The
service goals were adequate, however the plans
lacked detail regarding the progress towards
achievement of goals
.
 Discharge Planning: (SAGE) Minimal discharge
information was found on the discharge summaries.

excerpt:
(8) Written record of the administration of
medication includes:
(a) name
(b) description
(c) dates & times
(d) missed doses
(e) medication disposed
(f) method of administration
(g) ID of person administering
(h) possible adverse reactions
(i) medication taken outside facility Corrective Action

excerpt:
(q) Ability to respect spiritual beliefs,
sexual orientation, gender identity, and
gender expression, disabilities, national
origin, and cultural identities of each child
and provide opportunities to enhance the
positive self-concept and understanding
of child’s heritage

excerpt:
(u) Assessment and recommendations
including the characteristics and
maximum number of children who may be
placed in care Assessment and Approval of Proctor Foster Homes
Written Home Study includes the following:
413-215-0316(3) (u) Assessment and recommendations
including the characteristics and maximum number of
children who may be placed in care
 The above required information in the Assessment
and recommendation reviewed lacked adequate
detail regarding characteristics of children to be
placed in the homes.

excerpt:
(c) Attachment, separation, and loss
issues for children and families Orientation for Proctor Foster Homes Applicants 413-
215-0321(2) (c) Attachment, separation, and loss issues
for children and families
 Documentation of the above required orientation was
not consistently found in the files reviewed.

excerpt:
(c)(B) Ways to effectively parent children,
including application of the reasonable
and prudent parent standard Training for Parents in Proctor Foster Care
Written Training Plan includes:
413-215-0326(1) (c)(B) Ways to effectively parent
children, including application of the reasonable and
prudent parent standard
 Documentation of the above required training was
not consistently found in the files reviewed.

excerpt:
(c)(D) Importance of family of the child
and working with the family Training for Parents in Proctor Foster Care
Written Training Plan includes:
413-215-0326(1) (c)(D) Importance of family of the child
and working with the family
 Documentation of the above required training was
not consistently found in the files reviewed.

excerpt:
(c)(F) Preparation of child for
independence based on age, stage of
development, and child’s needs Training for Parents in Proctor Foster Care
Written Training Plan includes:
413-215-0326(1) (c)(F) Preparation of child for
independence based on age, stage of development, and
child’s needs
 Documentation of the above required training was
not consistently found in the files reviewed.

excerpt:
(c)(G) Legal responsibility to report
suspected child abuse Training for Parents in Proctor Foster Care
Written Training Plan includes:
413-215-0326(1) (c)(G) Legal responsibility to report
suspected child abuse
 Documentation of the above required training was
not consistently found in the files reviewed.

excerpt:
(a)The name, gender, date of birth,
religious preference, and previous
address Information about Children in Care 413-215-0396 (1)
Summary sheet contains the following: religious preference,
and previous address
 The above required information was not consistently
found in the files reviewed.

excerpt:
(b) Name and location of previous and
current school Information about Children in Care 413-215-0396 (1)
Summary sheet contains the following: (b) Name and
location of previous and current school
 The above required information was not consistently
found in the files reviewed.