summary: License Renewals - 8 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care
Licensee: Morrison Child and Family Services Date of site visit: November 4th – 7th, 2024
Executive Director: Nick Gallo Licensing Coordinator: Jorge Pelinski, Holly Ivey, Tom Heidt, and
Todd Cooley
Other Regulatory or Accrediting Agencies: The Joint Commission, HHS Administration for Children and Families, Office of Refugee and
Resettlement
Program Compliance: The program was found to be compliant or will be compliant with OAR 419-400-0005 to 419-400-0310, Licensing Umbrella
Rules, OAR 419-430-0010 to 419-430-0110, Licensing Day Treatment Agencies Rules, OAR 419-440-0010 to 419-440-0210, Licensing Foster
Care Agencies Rules and OAR 419-470-0010 to 419-470-0180, Licensing Residential Care Agencies Rules. Personnel records were reviewed and
compliance with required background checks was documented for employees in all programs.
Agency Description provided by Morrison Child & Family Services: Morrison provide a wide array of culturally responsive and trauma-informed
programs. Morrison provides mental health and substance use treatment, services for victims of sex trafficking and many other services. Morrison
Child and Family Services was founded by a group of concerned citizens and physicians committed to providing mental health services for
children in the community. Dr. Carl Morrison, one of Oregon’s first child psychiatrists, served as Morrison’s first Executive Director for 25 years. In
its first year, the Portland Community Child Guidance Clinic, as it was called, served 216 cases from a modest house in downtown Portland.
Individual Program Description(s) provided by Morrison Child & Family Services:
Counterpoint Day Treatment & Proctor Care - The Counterpoint Day Treatment and Proctor Care Program is a comprehensive program that
combines mental health and sexual offending treatment with an accredited school program and therapeutic proctor care. The day program is open
8:45 am to 4:00 p.m. Monday-Friday and serves adolescent males 12 to 17 years old that have sexual behavioral difficulties. Youth can be referred
to CPDT through a variety of sources i.e. families, ODHS, schools, although most referrals are made by the Oregon Youth Authority. Treatment
services occur throughout the day and include peer group meetings, treatment 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, DBT, assertiveness training, and healthy relationships. Youth have access to individual and family counseling,
medical follow-up 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 developmental problems from occurring later in their lives. The school day is provided by Portland
Public School teaching staff and youth receive high school credits. Cognitive-behavioral treatment strategies and mindfulness interventions are
used throughout the program. Morrison is certified in the Sanctuary Model, a trauma-informed evidence-based practice for organizational
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development and clinical service delivery. Counterpoint staff receive in depth Sanctuary training and are implementing team activities and
therapeutic activities that embody the Eight Commitments and the Sanctuary Toolkit (Community Meetings, Red Flag Meetings, SELF exercises,
Self-care Plans, and the Trauma Triangle).
Family members are encouraged to participate in day treatment, but their participation is not required for the youth to receive services. Visitation
with parents, siblings, and others is tailored to youth’s social, developmental, and treatment needs. Visitation is approved by legal guardians. The
geographic area served is the State of Oregon.
The client population served are predominantly adolescent males, 13-17 years old. During the recent past, CPDT has also served transgender
youth. Youth served have a range of racial and ethnic backgrounds including White (67%), multi-racial (19%), Hispanic/Latinx (8%), Black (2%), and
Native American (2%).
Our client to staff ratio is no more than 7 to 1. Services are provided by a staff team with experience in mental health and human services.
Currently, treatment staff have or are pursuing certification as Sexual Offense Therapists or Associate Therapists through the State of Oregon
Sexual Offense Treatment Board. The Program Director is a Licensed Clinical Social Worker (LCSW) and a Certified Clinical Sexual Offense
Therapist.
In addition to day treatment services most youth are also placed in a certified proctor foster home. Morrison Child and Family Services works
collaboratively with the Oregon Youth Authority to certify foster homes designed to serve this specialized population. Morrison Counterpoint staff
recruit, train, and support prospective proctor parents while the Oregon Youth Authority certifies the homes and the proctor parents. Proctor parents
are members of the day treatment team and receive on-going supervision and support from clinical staff. CPDT Proctor Care is considered
Therapeutic Foster Care and follows BRS Administrative Rules. Both day treatment and proctor care are accredited by The Joint Commission.
CPDT has an active QI Committee that meets quarterly to review program services and recommend improvements. Client demographics, client
satisfaction, and client outcome data are collected and compiled. Client satisfaction surveys from FY 23 and FY 24 showed that 90% of youth
expressed overall satisfaction with the services that they received.
Counterpoint Proctor Care Program – Youth who participate in the Counterpoint Day Treatment Program live with specialized therapeutic proctor
parents. Proctor parents provide care, supervision, and skills building for youth. Proctor parents have daily contact with day treatment program staff
and receive weekly, individualized supervision and support from day treatment therapists. CPDT has emphasized the provision of training and
supports to proctor parents teaching and supporting them in helping youth with difficult emotional and behavioral problems grow and change. The
recruitment and certification of the proctor homes is a joint venture between the Oregon Youth Authority and the Morrison Counterpoint Program.
Morrison provides the recruitment, training, and support to proctor parents and the Oregon Youth Authority formally certifies the homes. Currently,
five proctor homes are certified.
The Proctor Care component is accredited by The Joint Commission and certified by the Sanctuary Institute.
Mi Futuro – Mi Futuro is a 25-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 its doors in July 2014. It provides a temporary, 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 Mi
Futuro clinicians when needed. The primary goal of the Program is safe and quick family re-unification and services are designed to achieve this
goal.
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The Mi Futuro program is staffed with a Program Director, Assistant Director, Milieu Supervisors, Milieu Counselors, Case Managers, Clinicians,
Medical Services Coordinators, and Educational and Administrative staff. Youth living at Mi Futuro have assigned bedrooms and Morrison receives
many compliments about the attractiveness of this facility.
The Mi Futuro 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 Mi Futuro based upon assessments of their developmental and behavioral needs that indicate that
they can function safely and successfully in an open, less restrictive environment. Individual service needs and level of care are 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. They typically speak Spanish or Indigenous languages spoken in their home countries. In the
recent past, youth from Middle Eastern and African countries have also been referred. Agency data reflected that Mi Futuro served 196 youth, 109
Female and 87 Male, in FY23 and 165 youth, 84 Female and 81 Male, FY 24. Race/Ethnicity reported by the youth served in FY 23 included: 4
Multiracial and 125 Hispanic or Latino youth. The remaining youth reported: 32 Declined to Answer, 2 reported Other, and 33 were Unidentified. For
FY 24, 7 reported Multiracial, 90 Hispanic or Latino, 32 Declined to Answer, 4 American Indian or Alaska Native, 4 Other, and 28 did not identify a
race/ethnicity (Unidentified).
The Mi Futuro program has an active program QI Committee that meets regularly. Committee members review quality indicators and client
satisfaction data. Since the program’s inception Mi Futuro has successfully reunited 1500 youth with family members or sponsors in the United
States. 95% of youth who lived at Mi Futuro during FY 22 and FY 23 reported satisfaction with the services that they received; 95% felt emotionally
supported and 97% felt religiously, culturally, and ethnically respected.
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 public 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
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 preparing 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 under the age of 17 years, 6 months at the time of placement and
potential eligibility for “immigration” or “legal” relief.
The population served are primarily youth from Central or South America until recently when youth from Afghanistan and Africa have been referred.
They have entered the United States without a parent or legal guardian and without legal immigration status. Agency data reflected that LTGH
served 31 youth (13 Female and 18 Male), in FY22-23 and 23 youth (10 Female and 13 Male), FY 23-24. The Race/Ethnicity reported by the youth
served in FY 23 included: 2 White, 22 Hispanic or Latino, 4 Black or African American, 1 Other, and 2 Unidentified youth. For FY 24 15 Hispanic or
Latino youth, 4 Black or African American, 4 Unidentified youth were served.
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The Group Home is staffed with a Program Director, Assistant Director, Milieu Supervisors, Milieu Counselors, Skills Trainers, Case Managers, a
Clinician, a Medical Services Coordinator and Administrative staff. Most staff are Spanish speaking.
The Morrison Long-Term Group Home is licensed by the State of Oregon, Children’s Care Licensing Unit, as a residential care program, meets
federal ORR policy and guidance requirements, and is accredited through The Joint Commission.
The Long-Term Group Home program has an active QI Committee that reviews program data and client satisfaction data in addition to other
program-specific benchmarks. The Group Home program has 11/4/20; rev. 12/27/22; rev. 9/18/2024. Successfully reunited 42 youth with family
members or sponsors since its inception. Youth satisfaction surveys conducted in FY 22 and FY 23 report that 87% of youth served are satisfied
with services and their experiences at the Long-Term Group Home.
SAGE Residential – Morrison’s SAGE program is a 16 bed, secure residential treatment program for female identifying youth, ages 11 to 16.5
years, residents of the state of Oregon, who have experienced commercial sexual exploitation.
The program provides a full range of mental health treatment (individual, group, family, and psychiatric), substance abuse treatment, milieu therapy,
on- site education/a DARTS school, health care follow-up services, case management, and psychoeducation and treatment specific to commercial
sexual exploitation and sex trafficking. The SAGE program is trauma-informed and strengths-based. SAGE provides a level of safety for youth that
is not available in a less restrictive setting and collaborates with families and community partners to create effective systems of support while youth
are in the program and when they return to the community.
Agency data shows that SAGE provided services to 34 female youth in FY 23 and 31 female and 1 male identifying youth in FY 24. Youth served
provided the following Race/Ethnicity identification for FY 23 18 White, 5 Multiracial, 3 Hispanic or Latino, 3 Black or African American, 1 Other, and
4 Unidentified. For FY 24 13 White, 4 Multiracial, 1 Hispanic or Latino, 3 Black or African American, 1 Other, and 10 Unidentified youth were served.
The expected duration of the program is 11 to 14 months. In FY 23 the average length of stay was 233 days (7.6 months) and in FY 24, 323 days
(10.6 months). Data collected over the past 3 years from two standardized instruments demonstrates an overall positive impact of the program on
youth social and emotional strengths.
SAGE is funded through a contract with the Oregon Health Authority. Youth are referred by their legal guardians and may be in the custody of
ODHS or the Oregon Youth Authority. SAGE is licensed as a residential care program through the ODHS Children’s Care Licensing Program; holds
an Oregon Health Authority Certificate of Approval for ancillary Behavioral Health Services and is accredited by The Joint Commission.
Program type and services: Residential Care, Proctor Care, Planned Crisis Respite 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: 11 certified foster homes, capacity 17.
Counterpoint foster care: 5 certified foster homes, capacity - 14
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)
• 2023- 2-3 days
• 2024- 2-3 days
Counterpoint foster care:
• 2023- 265 days
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• 2024- 440 days
SAGE residential care:
• 2023 233 days
• 2024 323 days
Residential Care Program Update-Long Term Group Home:
• 2023- 95 days
• 2024- 233 days
Residential Care Program Update-Shelter:
• 2023- 28 days
• 2024- 28 days
Average daily population served: The average daily population was identified by program managers.
Planned Crisis Respite Foster Care:
• 2023- 38 children
• 2024- 24 children
Counterpoint foster care:
• 2023- 13 children
• 2024- 11 children
SAGE residential care:
• 2023-11 children
• 2024- 17 children
Residential Care Program Update-Long Term Group Home:
• 2023-8 children
• 2024-11 children
Residential Care Program Update-Shelter:
• 2023-19 children
• 2024- 15 children
Number of children served annually: Number of children served was identified by program managers.
Planned Crisis Respite Foster Care:
• 2023- 71 children
• 2024- 50 children
Counterpoint foster care:
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• 2023- 32 children
• 2024- 16 children
SAGE residential care:
• 2023-34 children
• 2024- 32 children
Residential Care Program Update-Long Term Group Home:
• 2023-31 children
• 2024- 23 children
Residential Care Program Update-Shelter:
• 2023- 196 children
• 2024-165 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: The Downtown Long-Term Group Home and Shelter. SAGE Staff are trained in the Mandt
Intervention System. Counterpoint Day Treatment and Morrison Foster Care are “hands off” programs. The staff are trained in NCI’s non-physical
interventions and de-escalation techniques.
Funding sources: Mi Futuro & LTGH – U.S. Health and Human Services (HHS) Office of Refugee Resettlement (ORR), Oregon Department of
Human Services (ODHS), Oregon Health Authority (OHA)
Contracts: ORR Residential Shelter Services, ORR Residential LTGH Services
Residential Care and Support for victims of Trafficking and Commercial Sexual Exploitation (CSEC) population
Sources for referrals: Federal Field Specialists, Parent/Guardians, ODHS Case Workers, OYA Probation and Parole Officers.
Use of seclusion or restraint: The Mandt System is utilized. Seclusion is NOT used in any Morrison program.
Interviews: At the Licensing Review 8 children, 1 foster parent, and 2 Respite Care Parents were interviewed. The following information was
gained during the interviews with the children:
• The children interviewed at Mi Futuro, LTGH, and SAGE felt like things are going well in the program.
• The children all reported being able to talk to people on their approved contact list.
• The kids in the program reported that what they like best about the program is they are treated equally, playing sports, support from staff,
and the staff help kids in need of changing their lives.
• All the kids interviewed reported enjoying the food. Some of the youths’ favorite foods include spaghetti, hot cakes, meatball subs, Korean
bowls, and hot Cheetos.
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• All the children in the program reported that their hygiene needs are met by the program.
• All the children interviewed feel comfortable talking to staff about their needs or concerns.
• All the children interviewed reported feeling respected by the staff.
• All the children interviewed reported feeling safe in the programs.
Counterpoint Interviews:
• The children interviewed at Counterpoint felt like things are going well in the program.
• The children reported being able to talk to people on their approved contact list.
• The children expressed gratitude for the treatment opportunities they receive in the program.
• The children interviewed feel comfortable talking to staff about their needs or concerns.
• The children interviewed reported feeling respected by the staff.
• The children interviewed reported feeling safe in the programs.
• One youth expressed that the program has a good balance of education.
Observations: 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 and in good repair.
LTGH, Mi Futuro, and SAGE had new furniture. The Counterpoint program was also observed to be well maintained and in good repair.
Program Challenges reported by Morrison Child & Family Services: SAGE program challenges include finding and retaining staff. Mi Futuro
and LTGH program challenges include finding and retaining staff to support the full capacity of the program facilities.
Changes that have occurred in the last 2 years reported by Morrison Child & Family Services: SAGE’s significant program changes include a
change in the Medical Director overseeing medical support for the program. Mi Futuro reduced capacity from a 50-bed program to a 25-bed
program, based upon the needs of the Federal ORR system. LTGH’s significant program changes include a new Program Director starting in 2023.
All three programs were re-accredited with Joint Commission in 2024.
PCRC - The significant change that occurred is the Therapeutic Foster Care (TFC) Program was closed on June 30, 2023, which was a significant
partner program with Planned & Crisis Respite Care (PCRC) Program. The staff of the TFC program moved on to other jobs within and outside of
the agency. With this changes PCRC’s funding source remained the same, but contract with Care Oregon changed to a 1/12 contract (capacity
payment). Prior to this PCRC billed per client per night of each respite stay. The PCRC program continues to work in a Hybrid model (remote work,
at the office at time, and within the community as needed). The program lost one position that was a program coordinating position and
administrative support and continues to adjust to this change with the PCRC team.
Lawsuits: Amended: One lawsuit in the last two years regarding a former Morrison residential care program that is now closed.
Grievances and complaints filed in the last two years: Morrison Child and Family Services Foster Care programs address all types of concerns,
complaints, and formal grievances raised by youth, parents, or staff. There were not formal grievances for Mi Futuro, LTGH, or SAGE for either FY
22-23 or FY 23-24. There were 2 total complaints for SAGE, 1 for FY 22-23 and 1 for FY23-24, both complaints were addressed and did not
escalate further. The Counterpoint Day Treatment Program tracks client complaints and grievances as a part of its quality improvement initiatives.
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During FY 23 and FY 24 there were no complaints submitted in FY 23 and one complaint was submitted in FY 24. The complaint was resolved
successfully by program staff.
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report (insert name of agency) must submit a letter of verification indicating the agency is in compliance with the
specific rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency must
submit any and all specific documentation requested in the body of this report. The letter of verification and any additional requested documents can
be emailed directly to (Licensing Coordinator and email address).
Recommendations: No recommendations
Exceptions: None
Changes in License: Downsized the number of beds in LTGH and Mi Futuro due to budget changes and federal government policy. The number
has changed from 70 to 45 youth in the two programs.
Summary of Review
Program and Services
Yes No N/A Corrective Actions/Comments
419-400-0020 (2)
Program and services are in scope of license x
Governance of the Agency
Yes No N/A Corrective Actions/Comments
419-400-0040
(1)(a) Minimum of 5 board members x
(2)(f) Formally evaluate the exec. Director’s
x
performance annually
(2)(g) Approves annual budget x
(2)(h) Obtain and review an annual
independent financial review or audit of x
financial records.
(2)(k) Written quality improvement program x
(2)(l) Meeting minutes x
Executive Director or Program Director
Yes No N/A Corrective Actions/Comments
419-400-0040
(3)(a) knowledge of requirements for
providing care and treatment appropriate to x
programs
(3)(g) Approval from BCU x
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Installation and Use of Video Equipment
Used to Monitor or Record Children in
Yes No N/A Corrective Actions/Comments
Care
419-400-0145
(1) If a child-caring agency installs video
equipment to monitor or record a child in
care, all employees, volunteers, parents or
x
guardians, and children in care must be
informed about the intended use and
locations of the equipment.
Discipline, Behavior Management, and
Suicide Prevention Yes No N/A Corrective Actions/Comments
419-400-0150
(3) Agency uses appropriate and positive
methods of behavior management and
x
nationally recognized non-violent crisis
intervention
(3)(b)(C) Agency does not use chemical and
mechanical restraint (excluding medically x
necessary devices/prescriptions)
(3)(c) Agency uses appropriate time-out
rooms (adequate space, heat, light and
ventilation and is not capable of locking) and x Program does not utilize time-outs
documents use in child’s record when
applicable
(3)(e) Agency uses seclusion
x Program does not utilize seclusion
appropriately/consistent with policy
(4) Agency has adequate plan in place to
x
respond to suicidal behavior/warning signs
Contractors (if applicable)
Yes No N/A Corrective Actions/Comments
419-400-0120(6)
(a) Agency ensures the contractor meets the
requirements of this rule and Chapter 413 x
division 215
(b)(B) Contract includes the following:
(i) Services provided
(ii) Contractor fees
(iii) Disclosure of information from contractor
to agency
(iv) Lines of authority x
(v) Adherence to rules, including background
check
(vi) Any liability of the agency for acts of the
contractor, rights of indemnity and limitations
on liability
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Restraints and Involuntary Seclusion
Yes No N/A Corrective Actions/Comments
419-400-0180
(13)(d) Each child caring agency that
submits a report under this section shall
make its quarterly report available to the
x
public upon request at the Child Caring
Agency’s main office and on the child caring
agency’s website if applicable.
Supplemental Information Provided by
Yes No N/A Corrective Actions/Comments
CCA
Documents as indicated on the form titled
x
“Renewal Licensing Required Documents”
Documents as indicated on form titled
“Required Financial Documents and x
Information”
All required policies and procedures as
x
identified in the “Umbrella Rules”
All required policies and procedures as
x
identified in “Agency Type Specific Rules”
Sage, Long Term Group Home (LTGH), Downtown Shelter Program
(ORR) Residential License
Physical Plant
Yes No N/A Corrective Actions/Comments
419-400-0090(3)(a) Foster Rights Posted (if
x
children in DHS custody)
419-400-0100(1) Sufficient safe space,
x
equipment, and office equipment
419-400-0230(12) License is posted in
x
common area at each facility
419-470-0020(2)(a) &(c) Buildings are
x
smoke free, clean and in good repair
419-470-0020 (2)(d) Rooms are free of
x
harmful drafts, odors, and excessive noise
419-470-0020 (2)(e) Rooms are adequate in
x
size and arrangement
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419-470-0020 (2)(f) System provides a
continuous supply of hot and cold water to x
taps located throughout the facility
419-470-0020 (2)(h) Building is well
ventilated and room temperature is within a x
normal comfort range
419-470-0030 (1) All parts of the facility
x
ensure the safety of children
Room and Space Requirements
Yes No N/A Corrective Actions/Comments
419-470-0030
(2) There is a separate living room or lounge x
area – 15 SF minimum per child
(5) There is a separate dining room with x
capacity for ½ of children in care and 15 SF
per child in care
(7) Laundry is separate from living, kitchen, x
and dining areas
(8) Separate storage areas are provided for x
food, kitchen supplies, utensils, clean linens,
soiled linens and clothing, cleaning supplies
and equip, poisons, chemicals, outdoor
recreational and maintenance equipment.
(Hazardous materials are properly labeled, in
original container and locked)
(9) Outdoor activity area is protected from x
vehicles and other hazards and of a size and
availability appropriate to the age and needs
of children in care
(11) Time-out rooms: Rooms used for time x The programs do not utilize time-outs.
out or quiet time must have adequate space,
heat, light and ventilation and must not be
capable of locking.
Room and Space Requirements
Bedrooms Yes No N/A Corrective Actions/Comments
419-470-0030(3)
(a) Adequate furnishings and personal items x
(b) Separate from rooms used for dining,
x
living, laundry, kitchen, and storage
(c) Meet Oregon Fire Code Requirements x
(d) Be an outside room, with a window that
operates as designed. If the window is
modified from its original design, the fire
x
marshal must approve the modification and
indicate this room still meets applicable
Oregon Fire Code.
(d) Ceiling at least 90 inches x
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(e) Minimum 60 SF per occupant x
(f) No more than 25 if dorm style x LTGH, Mi Futuro, and SAGE are not dorm style programs.
(g) Permanently wired fixtures x
(h) Window covering x
Room and Space Requirements
Bathrooms Yes No N/A Corrective Actions/Comments
419-470-0030(4)
(a)(A)&(B) 1:8 ratio for toilets and sinks x
(a)(D) Hot and cold running water, soap, and
x
approved hand drying options
(a)(E) 1:10 ratio for shower or bathtub x
(a)(E) Individual privacy x
(a)(F) Window covering x
(a)(G) Permanently wired fixtures x
(a)(H) Adequate ventilation x
(b)&(c) Wooden racks on floors are
prohibited and impervious shower mats are
x LTGH, Mi Futuro and SAGE do not use wooden racks on shower floors.
disinfected & dried daily be in good condition
and free of mold
Room and Space Requirements
Kitchen Yes No N/A Corrective Actions/Comments
419-470-0030(6)
(a) Used exclusively for storage, food
preparation, dishwashing, and activities
x
related to eating and food preparation
activities
(b) Walls, floors are easily cleanable x
(c) Equipment and utensils are easily
x
cleanable, durable, nontoxic, and kept clean
(e) Equipment is easy to clean beneath,
x
between and behind
Furnishings and Personal Items
Yes No N/A Corrective Actions/Comments
419-470-0040
(1) There is a bed with frame, x
(1)(b) clean mattress in good condition, with
x
a minimum thickness of five inches
(1)(c) a pillow in good condition x
(1)(d) a private dresser, closet, or similar
storage area for personal belongings that is x
readily accessible
(2) Linens are in good repair. There is a
waterproof mattress cover or mattress.
x
Linens are appropriate and towels and
washcloths are provided
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(3) Bedding is changed weekly or when
x
soiled
(4)&(5) Personal hygiene supplies and
x
appropriate clothing are provided
Food Services
Yes No N/A Corrective Actions/Comments
419-470-0070
(1)(a) Meals are arranged daily, consistent
with normal mealtimes that occur during the
x
hours of operation and provide snacks
between mealtimes
(1)(b) Menus are prepared in advance in
accordance with USDA guidelines, provide a
x
variety of foods and are adjusted for
seasonal changes including snacks
(1)(b) Menus are kept for at least 6 months x
(1)(c) Drinking water is freely available x
(2)(a) Food is stored, prepared & served in a
x
sanitary manner
(2)(c) & (d) Food products are obtained from
commercial suppliers (exception of fruits &
vegetables), unpasteurized juice is x
prohibited, and only Grade A pasteurized
and fortified milk in appropriate container.
Residential Care Safety
Yes No N/A Corrective Actions/Comments
419-470-0080
(2) Written emergency plan that includes x
(a) Identifying the types of emergencies most
likely to happen where the residential care x
agency is located
(b) Identifying a place to meet for each type
x
of emergency identified
(c) Identifying an alternate shelter if
x
necessary
(d) Ensuring access to necessary
x
medications or medical equipment
(e) How to help each child in care recover
x
after a disaster
(3) Telephone numbers for local police, fire
department, poison control, after hours
medical advice and other appropriate x
emergency numbers must be posted near all
telephones.
(4) Operative flashlights sufficient in number
x
are readily available to staff
P age 13 | 42
Form Rev. 1/2/2024
(5)(a) Evacuation drill occurs monthly under
varying conditions, is retained 2 years and
contains:
(A) identify of person conducting drill
(B) date & time
(C) notification method x
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
Umbrella Safety
Yes No N/A Corrective Actions/Comments
419-400-0200
(5)(b) Vehicle has insurance policy, is smoke x
free, safe operating condition, and has first
aid kit and fire extinguisher 2-A:10-BC
(1)(b)(A) Each vehicle used to transport a x
child in care must be: properly registered,
covered by an insurance policy in full force
and effect, maintained in safe operating
condition, and smoke-free.
(3) If a child-caring agency has a swimming x The programs do not utilize swimming pools.
pool on the premises that is accessible to
children in care or if a child-caring agency
plans to have children in care engage in
swimming, the child-caring agency must
have and adhere to policies and procedures
that address, at a minimum, providing
disclosures and obtaining consents,
assessing swimming ability of children in
care, and ensuring the safety of pool access.
(4)(a) The program protects children from x
potentially harmful items and materials.
(4)(b) Direct supervision of children who do x The youth in the program can adjust water temperatures.
not have the ability to adjust and control
water temperature
(4)(c) Light fixtures have protective covers x
unless designed to be used without one
Medication
Yes No N/A Corrective Actions/Comments
419-470-0100
(3)&(7)(e) Medications have a prescription
and are stored in the original container with x
prescription label
(4)&(5) Herbal supplements and remedies,
x
medical treatments, special diets, physical
P age 14 | 42
Form Rev. 1/2/2024
therapy, physical aides or limitations have a
written order signed by a physician or
qualified medical professional. A written
order, signed by a physician or qualified
medical professional, is also required before
a restriction on diet or physical activity is
imposed.
(7)(c) Medications are inaccessible to
children and stored behind at least two
x
locking mechanisms. This does not apply to
Naloxone.
(8) Medications are disposed in accordance
x
with state and federal law
(9) Written record of the disposal of
medications is maintained and includes:
(a) description and amount
(b) name x
(c) reason
(d) method
(e) staff & witness signature
(10) Written record of the administration of
medication includes:
(a) name
(b) description
(c) dates and times
(d) missed doses x
(e) medication disposed
(f) method of administration
(g) ID of person administering
(h) possible adverse reactions
(i) medication taken outside facility
Extracurricular, Enrichment, Cultural &
Social Activities Yes No N/A Corrective Actions/Comments
419-470-0110
(2) Children have ongoing opportunities to x
participate in at least one age-appropriate or
developmentally appropriate activity
Minimum Staffing Requirements
Yes No N/A Corrective Actions/Comments
419-470-0130
(1)&(2) Supervision is adequate for the type x
of program, location, age and type of
children, ability of supervisor to respond,
electronic back-up systems.
Minimum ratios are maintained:
P age 15 | 42
Form Rev. 1/2/2024
Under 30 months of age: 1:4
30 months to ˃ 6 years or non-ambulatory:
1:6
Ages 6 and older: 1:7
Overnight (staff awake)
1:10
(4)(a) When one staff on duty, there is x
additional staff immediately available with
max response time of 30 minutes
(5) There is at least one on-site employee x
authorized to apply the reasonable and
prudent parent standard
Sleeping Arrangements
Yes No N/A Corrective Actions/Comments
419-470-0140
(1) Children are in separate bedrooms than x
adults, unless parent and child, or there is
written approval from guardian/parent and
licensing coordinator
(2) There is adequate supervision of children x
when sleeping
(3) When assigning bedrooms a residential x
care agency must consider all of the
following:
(a) Chronological age
(b) Developmental age
(c) Gender identity
(d) Personal history, including medical,
mental health, behavioral health, and past
adverse experiences including any physical
or sexual abuse
Personnel Files
Yes No N/A Corrective Actions/Comments
419-400-0120
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
P age 16 | 42
Form Rev. 1/2/2024
(3)(d) Annual performance evaluations x
(3)(f) Record of personnel actions x
(3)(g) Termination date, reason for
x
termination
(3)(h) Current job description (1)(c)
Employee meets minimum qualifications x
stated in current job description
New Employee Orientation – Umbrella
Requirements (30 days) Yes No N/A Corrective Actions/Comments
419-400-0120(4)
(a) Agency policies and procedures x
(b) Ethical and professional guidelines x
Mi Futuro – 1 file was missing suicide prevention and intervention training for new
employee requirements.
LTGH – 1 file reviewed was missing 2024 suicide prevention and intervention training for
new employees.
(c) Suicide prevention and intervention x
Corrective Action:
• Programs will ensure suicide prevention and intervention training for new
employees are completed. The agency will submit it as part of the Corrective
Action Plan.
(d) Attributes of population served x
(e) & (5)(a) to (c) Mandatory reporting that
includes:
(a) legal definition of child abuse in ORS
418.257 and 419B.005 x
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
(f) Privacy laws x
.
(g) Emergency procedures x
New Employee Orientation
Residential (Prior to working alone and
Yes No N/A Corrective Actions/Comments
within 30 days)
419-470-0120(1)
(a) Discipline and behavior management
including de-escalation, crisis prevention,
positive behavior management, and x
disciplinary techniques that are non-punitive
in nature
P age 17 | 42
Form Rev. 1/2/2024
(b) CPR and First Aid sufficient to retain a
x
current certification
(c) Universal precautions and hygiene x
(d) Application of the reasonable and
x
prudent parent standard
ORR Programs - 2 out of 4 staff files reviewed did not have any training on this topic
listed. One staff file reviewed had the assessment tool training.
(e) Training on the agency’s policy on
suicide prevention and suicide risk x
Corrective Action:
assessment tool
• Agency will ensure this requirement is met and submit it as part of the Corrective
Action Plan.
Crisis Intervention Training Standards
and Certification Yes No N/A Corrective Actions/Comments
419-400-0160(4) (as applicable)
(a)Complete a minimum of 12 hours of initial
training in person from a certified instructor,
including but not limited to a minimum of six
hours of training focused on positive SAGE trains their staff in MANDT Training. This is the only program at Morrison that
x
behavior support, nonviolent crisis utilizes restraints.
intervention and other methods of
nonphysical intervention to support children
in care during a crisis
(d) Receive a certificate that states:
(A) The dates during which the certification
is current
(B) The type of restraint which the individual
is certified to perform if applicable
(C) The type of training the individual is
SAGE trains their staff in MANDT Training. This is the only program at Morrison that
certified to conduct if applicable x
utilizes restraints.
(D) Any special endorsements earned by the
individual
(E) The level of training
(F) The name of the certified instructor who
conducted the training and administered the
assessment of proficiency.
(e) A certification issued:
(A) Must be personal to the individual
SAGE trains their staff in MANDT Training. This is the only program at Morrison that
certified by the training provider x
utilizes restraints.
(B) May be valid for no more than two years
with recertification
Ongoing Training Yes No N/A Corrective Actions/Comments
P age 18 | 42
Form Rev. 1/2/2024
419-470-0070(2)(b) Employees who handle
food served to children have a valid food x
handler’s card
Mi Futuro – 2 staff files reviewed were missing ongoing training for this requirement.
419-400-0200 (1) Employees transporting
LTGH – 1 file reviewed was missing ongoing training for this requirement.
children have: current driver’s license,
insurance, trained in emergency procedures x
Corrective Action:
and behavior management, and training for
• Agency will ensure ongoing training for this requirement is completed and submit
15+ passenger vans if applicable)
it as part of the Corrective Action Plan.
ORR Programs – 3 files reviewed were missing ongoing training for Environmental
Emergencies.
SAGE - 3 out of 4 files reviewed were missing ongoing training for environmental
419-470-0120 (2)(a) Environmental emergencies – Have until the end of the year.
x
emergencies
Corrective Action:
• Agency will ensure ongoing training for environmental emergencies is completed
and include as part of the corrective action plan.
419-470-0120 (2)(b) Universal Precautions x
419-470-0120 (2)(c) Discipline and Behavior
x
Management
Mi Futuro – 1 file reviewed was missing ongoing training for suicide prevention and risk
assessment tool.
LTGH – 1 file reviewed was missing ongoing training for suicide prevention and risk
assessment tool.
SAGE – 1 file reviewed was missing ongoing training for suicide prevention and risk
419-470-0120 (2)(d) Agency’s policy on
x assessment tool.
suicide prevention and risk assessment tool
Corrective Action:
• Agency will ensure ongoing training for the suicide prevention and risk
assessment tool is completed and submit it as part of the Corrective Action Plan.
419-470-0120 (3) Staff providing direct care
must maintain current CPR/First Aid x
certification
419-470-0120 (4) Designated staff
authorized to apply reasonable and prudent
x
parent standard are trained in application of
the standard
419-400-0120(5) Mandatory reporting ORR - 3 out of 3 staff files reviewed were missing Mandatory Reporting Training.
x
(annually) that includes:
P age 19 | 42
Form Rev. 1/2/2024
(a) legal definition of child abuse in ORS Corrective Action:
418.257 and 419B.005 • Agency will ensure Mandatory Reporting training is completed. Agency will
(b) legal responsibility to immediately report submit this as part of the Corrective Action Plan.
(c) legal responsibility to report is personal to
the employee
419-400-0160(4)(b) Receive continuing
education (as applicable on crisis
x
intervention training) from a certified
instructor on an annual basis
Children’s Records Yes No N/A Corrective Actions/Comments
Health Services
419-470-0090
(2) Medical history obtained within 30 days
(significant findings, current immunizations,
history of surgical procedures-health issues- x
injuries, allergies, dental, vision, hearing,
behavioral health, and physician orders)
(4)(a) to (f) Medical exams (3 in first year of
life, 2,4,6,9,14) x
(g) Have a physical examination within the
first 60 days after admission of a child in
care. Documentation of a physical x
examination having occurred within the
calendar year will meet this requirement.
Consents
Yes No N/A Corrective Actions/Comments
419-470-0160(1)
(a) Provide routine and emergency medical
x
care
(b) Use the discipline and behavior
x
management system
(c) Use restraint or seclusion (if applicable).
Must specify the reasons for the intervention x
and how staff are trained and supervised
(d) Restrict contact with persons outside of
x
the agency
(e) Allow access as defined in 419-400-0230
x
& 0240
(f) Impose a dress code x
(g) Apply the reasonable and prudent parent
x
standard
P age 20 | 42
Form Rev. 1/2/2024
Disclosures
419-470-0160(2) Yes No N/A Corrective Actions/Comments
Parent/guardian has acknowledged in writing:
(a) Information regarding personal or room
searches and protocols for confiscation of x
contraband
(b) Statement of Rights of Children and
x
Parents/Guardians
(c) Any policies and procedures upon request x
Authorizations
Yes No N/A Corrective Actions/Comments
419-470-0160(3)
(a) Disclose or exchange information with
x
others
(b) Child specific visitors x
(c) Visitation resources are pre-approved x
(d) Activity specific authorizations are pre-
approved to allow children to participate in
potentially hazardous activities, including but x
not limited to using motorized yard
equipment, swimming, and horseback riding.
Information about Children in Care
419-400-0190(1) Yes No N/A Corrective Actions/Comments
Summary sheet contains the following:
(a)The name, gender, date of birth, religious
x
preference, and previous address
SAGE – 5 out of 5 staff files reviewed were missing name and location of previous and
current school.
(b) Name and location of previous and
x Corrective Action:
current school
• Program will ensure Name and location of current school is completed in the
summary sheet. Program will submit this as part of their Corrective Action Plan.
(c) Date of admission x
(d) Legal custody x
(e) The name, address, and telephone
number of:
(A) The child in care's parents.
(B) The child in care's legal guardian, if
different than the parents, and a copy of
x
the document that provides for his or her
authority over the child in care.
(C) Other persons significant to child
(D) Other professionals to be involved in
service planning (if applicable)
P age 21 | 42
Form Rev. 1/2/2024
Service Planning
Yes No N/A Corrective Actions/Comments
419-470-0170(2)
(b) Intake document is completed the date
child accepted into care (emergency x
placement 48 hours)
(d) Assessment is completed within 30 days
and contains relevant historical info., current
behavioral observations, identified need for x
services, and how agency will provide
services
(e) (A)&(B) Service plan within 60 days
(parent, guardian and child actively involved).
Describes how child’s issues will be x
addressed, anticipated outcomes, and
reviewed by child and guardian/parent.
(e)(C)&(D) Service plan is reviewed quarterly
and revised when information indicates other x
services should be provided
Case Management
Yes No N/A Corrective Actions/Comments
419-470-0170(3)
(a) Services are documented, progress
x
toward achieving goals is tracked
(c) Discharge summary must include:
(A)Current medications
(B)Name of the physician or qualified medical
professional who prescribed each medication
(C)Any outstanding medical or other
appointments x
(D)Summary of the child’s participation in the
program and progress achieved
(E)Results of evaluations
(F)Recommendations regarding services
(G)Discharge destination
(e) Follow up services x
(f) Incident Reports x
Records Relating to Restraint &
Yes No N/A Corrective Actions/Comments
Involuntary Seclusion
419-400-0180 (12) Records x
419-400-0180(13)(e) Each child caring Mi Futuro & LTGH - 5 out of 5 records reviewed were missing documentation indicating
agency shall provide notice regarding how to the notice regarding how to access the quarterly reports had been provided to the parents
access the quarterly reports to the parents or x or guardians of children in care in the program. The child caring agency shall provide the
guardians of children in care in the program. required notice upon the child in care’s admission and at least two times each year
The child caring agency shall provide the thereafter.
P age 22 | 42
Form Rev. 1/2/2024
notice upon the child in care’s admission and
at least two times each year thereafter. Corrective Action:
• Agency will ensure this requirement is met. Agency will submit this as part of the
Corrective Action Plan.
419-400-0190(1) Information provided to
children in care relating to Restraint & x
Involuntary Seclusion
Financial Records
Yes No N/A Corrective Actions/Comments
419-470-0170(4)
Records contain date, amount, source,
x
purpose, signatures
Personal Possessions Records
Yes No N/A Corrective Actions/Comments
419-470-0170 (5)
Individual written inventory of all personal
possessions is maintained and updated as x
needed
Records and Documentation
Yes No N/A Corrective Actions/Comments
419-400-0140
(1) Stored safely x
(2) Permanent, legible, dated, and signed x
(3) & (4) Uniform in organization, readily
identifiable and accessible, current, and
x
complete, containing all required info. No
eraser tape or white out.
(7) Permanent registry for each child
includes:
Name
Gender
x
Birth date
Names, addresses of parents or guardians
Dates of admission
Placement upon discharge
Comments:
Counter Point (Day Treatment)
Educational Services
Yes No N/A Corrective Actions/Comments
419-430-0110
P age 23 | 42
Form Rev. 1/2/2024
School is accredited
x
Accrediting body ___________________
(2) 1:15 ratio for qualified teacher/children
x
(4) Secondary schools – verification provided that meets academic
standards to obtain admission to higher education and receive high school x
diploma or GED
Physical Plant Yes No N/A Corrective Actions/Comments
419-400-0090(3)(a)Foster Rights Posted (if children in DHS custody) x
419-400-0100(1) Sufficient safe space, equipment, and office equipment. x
419-430-0030(8)(e) Classrooms and school buildings adequate in size and
x
arrangement for programs offered
419-400-0230(12) License is posted in common area at each facility x
419-430-0030(2) Buildings are clean and in good repair x
419-430-0030(3) Rooms are free of harmful drafts, odors, and excessive
x
noise
419-430-0030(4) Rooms are adequate in size and arrangement x
419-430-0030(5) System provides a continuous supply of hot and cold
x
water
419-430-0030(7) Building is well ventilated and room temperature is within
x
a normal comfort range
Room and Space Requirements
Yes No N/A Corrective Actions/Comments
419-430-0030
(8)(b) Laundry is separate from food storage, kitchen, and dining rooms x
(8)(c) Separate storage areas are provided for food, kitchen supplies,
utensils, clean linens, soiled linens and clothing, cleaning supplies and
x
equip, poisons, chemicals, outdoor recreational and maintenance
equipment
(8)(f) Time out rooms have adequate space, heat, light and ventilation and
x Program does not utilize time outs
is not capable of locking
(8)(g) Recreational activity area is protected from vehicles and other
hazards and of a size and availability appropriate to the age and needs of x
children in care
Room and Space Requirements
Bathrooms Yes No N/A Corrective Actions/Comments
419-430-0030(8)(a)
(A) 1:15 ratio for toilets x
(B) 1:2 ratio for sinks to toilets. Hand-washing sink not used for food prep x
(C) Hot and cold running water, soap, and approved hand drying options x
(D) Individual privacy x
(E) Permanently wired fixtures x
P age 24 | 42
Form Rev. 1/2/2024
(F) Window covering x
(G) Mirror, permanently affixed x
(H) Adequate ventilation x
Food Service Areas
Yes No N/A Corrective Actions/Comments
419-430-0030(8)(d)
(A) Areas used for storage, food preparation, and dish washing are
x
separate from child-caring areas
(B) Walls, floors are easily cleanable x
(C) Equipment and utensils are easily cleanable, durable, nontoxic, and
x
kept clean
(D) Equipment is easy to clean beneath, between and behind x
Food Services
Yes No N/A Corrective Actions/Comments
419-430-0060
(1)(a) Meals are arranged daily, consistent with normal mealtimes that
x
occur during the hours of operation
(b) Menus are prepared in advance in accordance with USDA guidelines,
x
provide a variety of foods and are adjusted for seasonal changes.
(b) Menus are maintained for at least 6 months Menus are not stored at Counterpoint. Menus are stored in
x
McDaniel High school where food is prepared.
(c) Drinking water is freely available x
(2)(a) Food is stored, prepared & served in a sanitary manner x
(2)(c) & (d) Food products are obtained from commercial suppliers
(exception of fruits & vegetables), unpasteurized juice is prohibited, and x
only Grade A pasteurized and fortified milk in appropriate container.
(2)(e) Children are supervised when in the food-preparation area x
Day Treatment Safety
Yes No N/A Corrective Actions/Comments
419-430-0070
(2)(a) Written emergency plan x
(2)(b) Telephone numbers for local police and fire are posted near all x
telephones
(2)(c) Operative flashlights sufficient in number are readily available to staff x
(3)(a) Evacuation drill occurs monthly under varying conditions, is retained x Program is missing the February 2023 fire drill. It was not
2 years and contains: completed.
(A) identity of person conducting drill
(B) date & time Corrective Action:
(C) notification method • Program will ensure that all fire drills are completed
(D) staff participating monthly and submit this as part of the Corrective
(E) # of children & staff evacuated Action Plan.
(F) special conditions simulated
(G) problems encountered
(H) time to complete
Umbrella Safety
Yes No N/A Corrective Actions/Comments
419-400-0200
P age 25 | 42
Form Rev. 1/2/2024
(5)(b) Vehicle has insurance policy, is smoke free, safe operating
x
condition, and has first aid kit and fire extinguisher 2-A:10-BC
(1)(b)(A) Each vehicle used to transport a child in care must be: properly
registered,
x
covered by an insurance policy in full force and effect, maintained in safe
operating condition, and smoke-free.
(3) If a child-caring agency has a swimming pool on the premises that is The agency does not have a swimming pool on the premises
accessible to children in care or if a child-caring agency plans to have that is accessible to children in care.
children in care engage in swimming, the child-caring agency must have
x
and adhere to policies and procedures that address, at a minimum,
providing disclosures and obtaining consents, assessing swimming ability
of children in care, and ensuring the safety of pool access.
(4)(a) The program protects children from potentially harmful items and
x
materials.
(4)(b) Direct supervision of children who do not have the ability to adjust All children in the program have the ability to adjust and
x
and control water temperature control water temperatures.
(4)(c) Light fixtures have protective covers unless designed to be used
x
without one
Medication
Yes No N/A Corrective Actions/Comments
419-430-0090
(2)&(5)(e) Medications have a prescription and are stored in the original
x
container with prescription label
(5) Medications are kept in locked storage x
(6) Medications are disposed in accordance with state and federal law x
(7) Written record of the disposal of medications is maintained (description,
x
name, reason, method, staff & witness signature)
Staff Qualifications and Minimum Staffing Requirements
Yes No N/A Corrective Actions/Comments
419-430-0020
(1) Teachers are licensed in accordance with Teachers Standards and
x
Practices Commission
(2) A qualified clinical supervisor directs the clinical program and
x
supervises clinical staff
(3) Mental health service delivery staff meet the qualifications in OAR 309-
x
022-0125
(4) Sufficient QMHP and other staff to meet the severity and acuity of
children served. Does not exceed 1:12 QMHP
x
Current Ratios__________________
413-215-0001(5)(f) Ensures safety and adequate supervision x
413-215-0001(5)(c) Engages in and applies appropriate behavior
x
management techniques
P age 26 | 42
Form Rev. 1/2/2024
Personnel Files
Yes No N/A Corrective Actions/Comments
419-400-0120
Name x
Position x
(3)(g) Date of Hire x
(3)(a) record of education, training, and previous employment x
(1)(b) & (3)(b) reference checks complete and documented x
(1)(a) & (3)(c) Background check was completed and documented x
(3)(d) Annual performance evaluations x
(3)(f) Record of personnel actions x
Of the files reviewed none of the employees were
(3)(g) Termination date, reason for termination x
terminated.
(3)(h) Current job description (1)(c) Employee meets minimum
x
qualifications stated in current job description
New Employee Orientation- Umbrella Requirements (30 days)
Yes No N/A Corrective Actions/Comments
419-400-0120(4)
(a) Agency policies and procedures x
(b) Ethical and professional guidelines x
(c) Suicide prevention and intervention x
(d) Attributes of population served x
(e) & (5)(a) to (c) Mandatory reporting that includes:
(a) legal definition of child abuse ORS 419B.005, Oregon Laws 2016,
chapter 106, section 36 x
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to the employee
(f) Privacy laws x
(g) Emergency procedures x
Crisis Intervention Training Standards and Certification
Yes No N/A Corrective Actions/Comments
419-400-0160(4) (as applicable)
(a)Complete a minimum of 12 hours of initial training in person from a
certified instructor, including but not limited to a minimum of six hours of
The staff are not trained to utilize restraints as it is not
training focused on positive behavior support, nonviolent crisis x
permitted to utilize in the program.
intervention and other methods of nonphysical intervention to support
children in care during a crisis
(d) Receive a certificate that states:
(A) The dates during which the certification is current
(B) The type of restraint which the individual is certified to perform if The staff are not trained to utilize restraints as it is not
x
applicable permitted to utilize in the program.
(C) The type of training the individual is certified to conduct if applicable
(D) Any special endorsements earned by the individual
P age 27 | 42
Form Rev. 1/2/2024
(E) The level of training
(F) The name of the certified instructor who conducted the training and
administered the assessment of proficiency.
(e) A certification issued:
(A) Must be personal to the individual certified by the training provider
The staff are not trained to utilize restraints as it is not
(B) May be valid for no more than two years with recertification x permitted to utilize in the program.
Ongoing Training Yes No N/A Corrective Actions/Comments
419-430-0060(2)(b) Employees who handle food served to children have
x
a valid food handler’s card
1 out of 3 files were missing documentation of ongoing
training for Mandatory Reporting.
419-400-0120(5) Mandatory reporting (annually) that includes:
(a) legal definition of child abuse in ORS 418.257 and 419B.005
x Corrective Action:
(b) legal responsibility to immediately report
• Program will ensure ongoing training is completed
(c) legal responsibility to report is personal to the employee
for Mandatory Reporting. Agency will submit this as
part of the Corrective Action Plan.
419-400-0200(1) Employees transporting children meet the driver
requirements (current driver’s license, insurance, trained in emergency
x Program does not have 15+ passenger vans.
procedures & behavior management, and training for 15+ passenger
vans if applicable)
419-400-0160(4)(b) Receive continuing education (as applicable on crisis
x The program does not utilize restraints.
intervention training) from a certified instructor on an annual basis
Children’s Records Yes No N/A Corrective Actions/Comments
Name of Child x
Date of admission x
Medication
Yes No N/A Corrective Actions/Comments
419-430-0090
(3) Medical treatments, special diets, physical therapy, physical aides, or
limitations have a written order signed by a physician or qualified medical x
professional.
(4) Self-administration is approved in writing by Physician, recommended Youth are not permitted to self-administer medication in the
x
by agency, and monitored by staff or guardian. program.
(9) If applicable, there is documentation of the continuing evaluation of Youth are not permitted to self-administer medication in the
x
the ability of the child to self-administer medication program.
(8) Medication record x
Records Relating to Restraint & Involuntary Seclusion Yes No N/A Corrective Actions/Comments
419-400-0180 (12) Records x
P age 28 | 42
Form Rev. 1/2/2024
This required documentation was not found in all records
reviewed.
419-400-0180(13)(e) Each child caring agency shall provide notice
Corrective Action:
regarding how to access the quarterly reports to the parents or guardians
• Program shall provide notice regarding how to
of children in care in the program. The child caring agency shall provide x
access the quarterly reports to the parents or
the notice upon the child in care’s admission and at least two times each
guardians of children in care in the program.
year thereafter.
Program will submit this as part of the Corrective
Action Plan.
419-400-0190(1) Information provided to children in care relating to
x
Restraint & Involuntary Seclusion
Records and Documentation
Yes No N/A Corrective Actions/Comments
419-400-0140
(1) Stored safely and are available for inspection by Dept. x
(2) Permanent, legible, dated, and signed x
(3)&(4) Uniform in organization, readily identifiable and accessible,
current, and complete, containing all required info. No eraser tape or x
white out.
(7) Permanent registry for each child includes:
Name
Gender
Birth date x
Names, addresses of parents or guardians
Dates of admission
Placement upon discharge
Comments:
Treatment Foster Care
Medication
Yes No N/A Corrective Actions/Comments
419-440-0180
(2)&(5)(e) Medications have a prescription and are stored in the
x
original container with prescription label
(3) Medical treatments, special diets, physical therapy, physical aids or
limitations have a written order signed by a physician or qualified x
medical professional.
(4) Self-administering medications by a child is approved in writing by
x
physician, recommended by agency, and closely monitored
P age 29 | 42
Form Rev. 1/2/2024
(6) Medications are disposed in accordance with state and federal law x
(7) Written record of the disposal of medications includes:
(a) description
(b) name
x
(c) reason
(d) method
(e) staff & witness signature
(10) Written record of the administration of medication includes:
(a) name
(b) description
(c) dates, times
(d) missed doses
x
(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
Yes No N/A Corrective Actions/Comments
419-440-0130
(2) Placement is consistent with recommendations in the current home
x
assessment
(3) Home does not exceed:
(a) 4:1 ratio approved proctor foster parent
x
(b) 6:2 ratio approved proctor foster parents
(c) 2 children under the age of 3
(6) At time of placement the agency provides proctor foster home
parents with:
(a) Child’s name, date of birth and reason for placement x
(b) Name and phone# of assigned worker
(c) Information on health, behavioral characteristics and needs of child
(d) Authorization and written instructions for obtaining medical, dental,
x
and other and emergency care
Respite Care
Yes No N/A Corrective Actions/Comments
419-440-0150
(1) Agency has and adheres to a respite care policy x
(2)(a) Alternate caregivers are
(A) at least 21 years of age and x
(B) have completed background checks
(2)(b) Agency approval is received prior to using respite care x
(2)(c) Proctor foster home notifies agency in advance when providing
x
respite care that will exceed max number of children authorized
(2)(d)&(e) Respite care plan for each child and includes emergencies x
P age 30 | 42
Form Rev. 1/2/2024
Records of Proctor Foster Homes
Yes No N/A Corrective Actions/Comments
419-440-0120
Last Name of Proctor Foster Parent(s) x
(2)(a) Certificate that includes: age range of children,
restrictions or limitations, and statement that the home meets x
standards established in these rules
(2)(b) & 419-440-0040(4) Notification of acceptance or denial of
application. If denial is due to substantiated abuse, the reason x
for denial is disclosed to applicant.
(2)(d) All documents pertaining to formal complaints. See also
x
413-215-0336
(2)(e) and 419-440-0130(5) Signed contract x
(2)(f) List of all children placed that includes identifying and
placement information x
419-440-0130(4) Documentation of the basis for placement
(2)(g) Documentation of home visit (every 90 days) x
(3) Documentation of changes in address, name and household
x
composition, and exceptions or suspensions
(4) Documentation of inactive status (if applicable) x
419-440-0030(1)(a) at least 21 years of age x
419-440-0100 Written notice to proctor foster home if
x
decertified
Assessment and Approval of Proctor Foster Homes
Written Assessment - Initial Yes No N/A Corrective Actions/Comments
419-440-0040
(1)&(2) Assessment is based on an on-site review of the home,
observations and interviews of each household member,
x
background check, any information gathered during
assessment.
(2)(a) Application signed by all applicants x
(2)(b) Home is primary residence and where each child will
x
reside
(2)(c) Statement of physical and mental health x
(2)(d) Report from licensed health care or mental health
x
professional if determined appropriate by agency
(2)(e) Minimum of 4 references (only one can be relative) x
(2)(f) Contact information for 2 individuals if applicant displaced
x
by natural disaster
Assessment and Approval of Proctor Foster Homes Initial
Written Home Study includes the following: Yes No N/A Corrective Actions/Comments
419-440-0040(3)
(b) Names and ages of children in the home and children no
x
longer in the home
P age 31 | 42
Form Rev. 1/2/2024
(c) Background check for all household members over 18 and
x
those under 18 as determined appropriate
(d) Background check from every state (or country) of
residence in last 5 years for household members over 18 and x
those under 18 as determined appropriate
(e) Placement preferences x
(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 additional support
x
services
(l) Marital history, including previous marriages, divorces, and
x
long-term relationships
(m) Parenting skills and values x
(n) Lifestyle x
(o) Religion or spiritual beliefs x
(p) Cultural background and experiences with diverse cultural
x
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 x
enhance the positive self-concept and understanding of child’s
heritage
(r) Assessment of current and previous licenses, certifications,
and other applications for providing care including adults.
x
Information must include any denials, suspensions revocations,
or terminations
(s) Assessment of the areas in which training is needed and the
plan of the agency for providing needed training and x
timeframes
(t) Applicant’s home and community x
(u) Assessment and recommendations including the
characteristics and maximum number of children who may be x
placed in care
Standards for the Proctor Foster Home Environment
419-440-0050 Yes No N/A Corrective Actions/Comments
(1)(a) the primary residence of the applicant and where the
x
child in care will reside
(1)(b) adequate space including space for safe and appropriate
x
sleeping arrangements for each child in care
(1)(c) child in care and parent/guardian must be notified of any
x
electronic monitoring that occurs in the home
(1)(d) posted Foster Children’s Bill of Rights x
P age 32 | 42
Form Rev. 1/2/2024
(1)(g) Authorization must be received from the agency and
parent/guardian prior to the beginning of hunting or target x
practice by the child
(2)(a) If there are potential hazards in or around the home, a
plan to prevent exposure of the child to the hazard must be x
developed and approved by the agency
(2)(d) Home and furnishings must be clean and in good repair
x
and grounds must be maintained
(2)(e) No accumulation of garbage or debris x
(2)(f) Home has an adequate source of safe water to be used
x
for personal hygiene
(2)(g) There is a provision for safe storage and administration
x
of all medications in the household
(2)(i)(A) Children may not be exposed to any second-hand
x
smoke in home or vehicle.
(2)(i)(B) Household members may not provide any form of
x
tobacco, nicotine, or other product illegal for a minor to possess
(2)(i)(C) All products referenced in (B) must be stored safe and
x
in a manner inaccessible to children
(3)(a) The home must have the following:
(A) working smoke alarm in each bedroom where a child in x
care sleeps within 24 hours of the time the applicant is certified
(B) A working carbon monoxide detector within 15 feet of each
bedroom where a child in care sleeps and at least one on each x
floor within 24 hours of the time the applicant is certified
(C) At least one operable fire extinguisher rated 2-A:10-B-C or
x
higher within 24 hours of the time the applicant is certified
(F) a written comprehensive home evacuation planed shared
with each child in care at time of placement and practiced at
least every six months. The written plan must include a x
provision for the safe exit of a child in care who is not capable
of understanding or participating in the evacuation plan.
(G) Interior doors that lock must be operable from both sides of
x
the door.
(3)(b) Each bedroom used by a child in care must have:
x
(A) At least one unrestricted exit
(B) At least one secondary means of exit or rescue x
(D) Unrestricted, direct access at all times to hallways,
x
corridors, living rooms, or other such common areas
(E) Quick release mechanisms on all barred windows x
(4)(a) Maintain and share emergency preparedness plan with
foster care agency. At minimum the plan will include:
x
(A) types of emergencies most likely to happen where the
proctor foster home is located
P age 33 | 42
Form Rev. 1/2/2024
(B) Identifying a place to meet for each type of emergency
identified
(C) Identifying an alternate shelter if necessary
(D) Ensuring access to all necessary medication or medical
equipment
(E) How to help each child in care recover after a disaster
(4)(b) Maintain a comprehensive list of emergency telephone
numbers including 911 and poison control and post in x
prominent place in the home
(5)(d) Written authorization must be received by proctor foster
x
home prior to transporting a child out of state or country
(5)(e) Proctor foster home must request approval from
x
Department no less than 90 days prior to international travel
Annual Review and Approval
419-440-0080(2) Yes No N/A Corrective Actions/Comments
(a) Updated home study x
(b) Background check(s) x
(d) Out of state background check (if applicable) x
(e) Documentation that home remains in compliance with safety
x
standards 419-440-0050
(f) Recommendation to approve or deny re-issuance of
x
certificate
Orientation for Proctor Foster Homes Applicants 419-440-
Yes No N/A Corrective Actions/Comments
0060(2)
(a) & 419-400-0120(4)(a) Policies and procedures of the
x
agency
(b) & 419-400-0120(4)(d) Attributes of population. Needs and
x
characteristics of children needing placement
(c) Attachment, separation, and loss issues for children and
x
families
(d) Importance of cultural identity and ways to foster this
x
identity
(e) Impact of foster care on child and family x
(f) Rights and responsibilities of proctor foster parent and
x
agency
(g) Resources available x
(h) Confidentiality x
(i) Rights of families and children x
(j) Provided copies of
(A) Program statement
(B) Requirements for Proctor Homes
x
(C) Policies of agency governing proctor foster homes
(D) Training requirements
(E) Licensing rules
P age 34 | 42
Form Rev. 1/2/2024
(F) Expectations for working with the agency
Orientation – Umbrella
Requirements (30 days) Yes No N/A Corrective Actions/Comments
419-400-0120(4)
(b) Ethical and professional guidelines x
(c) Suicide prevention and intervention x
(e) & (5)(a) to (c) Mandatory reporting that includes:
(a) legal definition of child abuse in ORS 418.257 and
419B.005 x
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to the employee
(f) Privacy laws x
(g) Emergency procedures x
Crisis Intervention Training Standards and Certification
Yes No N/A Corrective Actions/Comments
419-400-0160(4) (as applicable)
(a)Complete a minimum of 12 hours of initial training in person
from a certified instructor, including but not limited to a
minimum of six hours of training focused on positive behavior
x The program doesn’t use restraint or seclusion.
support, nonviolent crisis intervention and other methods of
nonphysical intervention to support children in care during a
crisis
(d) Receive a certificate that states:
(A) The dates during which the certification is current
(B) The type of restraint which the individual is certified to
perform if applicable
(C) The type of training the individual is certified to conduct if
x The program doesn’t use restraint or seclusion.
applicable
(D) Any special endorsements earned by the individual
(E) The level of training
(F) The name of the certified instructor who conducted the
training and administered the assessment of proficiency.
(e) A certification issued:
(A) Must be personal to the individual certified by the training
x The program doesn’t use restraint or seclusion.
provider
(B) May be valid for no more than two years with recertification
Training for Parents in Proctor Foster Care Written
Training Plan includes: Yes No N/A Corrective Actions/Comments
419-440-0070
(a) Minimum of 16 hours of training before placement x
(b) Minimum of 16 hours training annually prior to approval x
(c)(A) Characteristics and needs of children who are placed x
P age 35 | 42
Form Rev. 1/2/2024
(c)(B) Ways to effectively parent children, including application
x
of the reasonable and prudent parent standard
(c)(C) Positive behavior management x
(c)(D) Importance of family of the child and working with the
x
family
(c)(E) Importance of age-appropriate or developmentally
appropriate extracurricular, enrichment, cultural, and social x
activities
(c)(F) Preparation of child for independence based on age,
x
stage of development, and child’s needs
(c)(G) Legal responsibility to report suspected child abuse x
(c)(H) Cardiopulmonary resuscitation (CPR) and first aid
x
training sufficient to retain a current certification.
(c)(I) Medication administration. x
(c)(J) Emergency preparedness and planning. x
(2) Training is documented x
Personnel Files
Yes No N/A Corrective Actions/Comments
419-400-0120
Staff Name x
Position x
(3)(g) Date of Hire x
(3)(a) record of education, training, and previous employment x
(1)(b) & (3)(b) reference checks completed and documented x
(1)(a) & (3)(c) Background check completed and documented x
(3)(d) Annual performance evaluations x
(3)(f) Record of personnel actions x
(3)(g) Termination date, reason for termination x No files reviewed belonged to staff that were terminated.
(3)(h) Current job description x
New Employee Orientation – Umbrella Requirements (30
days) Yes No N/A Corrective Actions/Comments
419-400-0120(4)
(a) Agency policies and procedures x
(b) Ethical and professional guidelines x
(c) Suicide prevention and intervention x
(d) Attributes of population served x
(e) & (5)(a) to (c) Mandatory reporting (annually) that includes:
(a) legal definition of child abuse ORS 419B.005, Oregon Laws x
2016, chapter 106, section 36
P age 36 | 42
Form Rev. 1/2/2024
(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 – Foster Care (30 days)
Yes No N/A Corrective Actions/Comments
419-440-0160
(1)(a) Discipline and behavior management including de-
escalation, crisis prevention, positive behavior management, and x
disciplinary techniques that are non-punitive in nature
(1)(b) Restraint and seclusion
x Agency does NOT utilize restraint and seclusion.
(If applicable)
Crisis Intervention Training Standards and Certification
Yes No N/A Corrective Actions/Comments
419-400-0160(4) (as applicable)
(a)Complete a minimum of 12 hours of initial training in person
from a certified instructor, including but not limited to a minimum
The staff are not trained to utilize restraints as it is not permitted
of six hours of training focused on positive behavior support, x
to utilize in the program.
nonviolent crisis intervention and other methods of nonphysical
intervention to support children in care during a crisis
(d) Receive a certificate that states:
(A) The dates during which the certification is current
(B) The type of restraint which the individual is certified to
perform if applicable
The staff are not trained to utilize restraints as it is not permitted
(C) The type of training the individual is certified to conduct if x
to utilize in the program.
applicable
(D) Any special endorsements earned by the individual
(E) The level of training
(F) The name of the certified instructor who conducted the
training and administered the assessment of proficiency.
(e) A certification issued:
(A) Must be personal to the individual certified by the training The staff are not trained to utilize restraints as it is not permitted
x
provider to utilize in the program.
(B) May be valid for no more than two years with recertification
Ongoing Training Yes No N/A Corrective Actions/Comments
2 out of 4 files reviewed were missing documentation of ongoing
training for Environmental Emergencies.
419-440-0160(2)(a) Environmental emergencies x
Corrective Action:
P age 37 | 42
Form Rev. 1/2/2024
• Program will ensure that ongoing training for
environmental emergencies is completed and submit it as
part of the corrective action plan.
419-440-0160(2)(b) Universal Precautions x
2 out of 4 staff files reviewed were missing documentation of
ongoing training for Discipline and Behavior Management.
Corrective Action:
419-440-0160(2)(c) Discipline and Behavior Management x
• Program will ensure that ongoing training for Discipline
and Behavior Management is completed. The program
will include and submit as part of the corrective action
plan.
1 out of 4 staff files reviewed were missing documentation of
CPR/First Aid certification.
Corrective Action:
• Program will ensure that ongoing training for CPR/First
Aid certification is completed. The program will submit it
419-440-0160(3) Maintain current CPR/First Aid certification x
as part of the Corrective Action Plan.
Amended: Report has been amended on 1-14-2025; the staff
person in question does not work directly with children, so they
are not required to have CPR/1st Aid training.
No further actions needed.
3 out of 4 files reviewed were missing documentation of training
related to the reasonable prudent standard and developmentally
appropriate activities.
419-440-0160(4) Training related to the reasonable and prudent
x
parent standard and developmentally appropriate activities Corrective Action:
• Program will ensure training related to the reasonable
and prudent parent standard is completed. The program
will submit it as part of the Corrective Action Plan.
419-400-0120(5) Mandatory reporting that includes:
(a) legal definition of child abuse in ORS 418.257 and 419B.005
x
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to the employee
419-400-0160(4)(b) Receive continuing education (as applicable
on crisis intervention training) from a certified instructor on an x
annual basis
Comments:
P age 38 | 42
Form Rev. 1/2/2024
Children’s Records Yes No N/A Corrective Actions/Comments
Name x
Initial Evaluation
Yes No N/A Corrective Actions/Comments
419-440-0190(2)
(a) Agency request and review all available reports of child’s
past and present behavior, educational status, and physical and x
mental health.
(b) Preliminary determination whether prospective child has
disorders, disabilities, or deficits for which care, supervision, x
training, rehab, or treatment is needed
Information about Children in Care
419-440-0210(1) Yes No N/A Corrective Actions/Comments
Summary sheet contains the following:
(a)The name, gender, date of birth, religious preference, and
x
previous address
All files reviewed were missing name and location of previous
and current school.
Corrective Action:
(b) Name and location of previous and current school x
Program will ensure name and location of previous and current
school are documented on summary sheets. The program will
submit it as part of the corrective action plan.
(c) Date of admission x
(d) Legal custody x
(e) The name, address, and telephone number of:
(A) The child's parents.
(B) The child's legal guardian, if different than parents, and
legal relationship x
(C) Other persons significant to child
(D) Other professionals to be involved in service planning (if
applicable)
(f) Required consents and authorizations x
Records Relating to Restraint & Involuntary Seclusion Yes No N/A Corrective Actions/Comments
419-400-0180 (12) Records x
419-400-0180(13)(e) Each child caring agency shall provide
Refer families to website – add a line to the restraint seclusion
notice regarding how to access the quarterly reports to the
disclosure form on where to find this information and provide to
parents or guardians of children in care in the program. The x
parents/guardians twice a year thereafter. Recommend putting it
child caring agency shall provide the notice upon the child in
on the Service Plan.
care’s admission and at least two times each year thereafter.
419-400-0190(1) Information provided to children in care
x
relating to Restraint & Involuntary Seclusion
Health Services Yes No N/A Corrective Actions/Comments
P age 39 | 42
Form Rev. 1/2/2024
419-440-0170
(2) Medical history obtained within 30 days
(a) significant findings
(b) current immunizations, history of surgical procedures-health
issues-injuries x
(c) allergies
(d) dental, vision, hearing, behavioral health, and
(f) physician orders
(2)(e) Documentation of age-appropriate instruction –
pregnancy prevention, nutrition, prevention of HIV & AIDS, and x
prevention and treatment of sexually transmitted disease
(3) Agency provides or arranges for
(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
Yes No N/A Corrective Actions/Comments
419-440-0200(1)
(a) Provide routine and emergency medical care x
(b) Use the discipline and behavior management system x
(c) Use restraint or seclusion (if applicable). Must specify the
reasons for the intervention and how staff and proctor foster x
home parents are trained and supervised
(d) Restrict contact with persons outside of the agency x
(e) Allow access as defined in
x
419-400-0230 & 0240
(f) Impose a dress code x
(g) Apply the reasonable and prudent parent standard x
Disclosures
419-440-0200(2) Yes No N/A Corrective Actions/Comments
Parent/guardian has acknowledged in writing:
(a) Mandatory child abuse reporting requirements x
(b) Information regarding personal or room searches and
x
protocols for confiscation of contraband
(c) Statement of Rights of Children and Parents/Guardians x
(d) Grievance policies and procedures x
(e) Any policies and procedures upon request x
P age 40 | 42
Form Rev. 1/2/2024
Authorizations
Yes No N/A Corrective Actions/Comments
419-440-0200(3)
(a) Disclose information x
(b) Child specific visitors x
(c) Visitation resources are pre-approved x
(d) Activity specific authorizations are pre-approved to allow
children to participate in potentially hazardous activities,
x
including but not limited to using motorized yard equipment,
swimming, and horseback riding.
Service Planning
Yes No N/A Corrective Actions/Comments
419-440-0210(2)
(a) All documentation written in terms that are easily understood x
(b) Intake document is completed the date child accepted into
x
care (emergency placement 48 hours)
(c) Child is served according to an individual service plan that
x
outlines goals for services and care coordination
(d) Assessment is completed within 30 days and contains
relevant historical info., current behavioral observations,
x
identified need for services, and how agency will provide or
coordinate services
(e) (A)&(B) Service plan within 60 days (parent, guardian and
child actively involved). Describes how child’s issues will be
x
addressed, anticipated outcomes and reviewed by child and
guardian/parent.
(e)(C)&(D) Service plan is reviewed quarterly and revised when
x
information indicates other services should be provided
Case Management
Yes No N/A Corrective Actions/Comments
419-440-0210(3)
(a) Services are documented, progress toward achieving goals
x
is tracked
(b)-(d) discharge planning and instructions x
(e) Follow-up services identified (if applicable) x
(f) Incident Reports x
Financial Records
Yes No N/A Corrective Actions/Comments
419-440-0210(4)
Records contain (if applicable)
(a) date, amount,
(b) source x
(c) purpose
(d)&(e) signatures
P age 41 | 42
Form Rev. 1/2/2024
Personal Possessions Records
Yes No N/A Corrective Actions/Comments
419-440-0210(5)
Individual written inventory of all personal possessions is
x
maintained and updated as needed
Records and Documentation
Yes No N/A Corrective Actions/Comments
419-400-0140
(1) Stored safely x
(2) Permanent, legible, dated, and signed x
(7) Permanent registry for each child in care includes (name,
gender, birth date, names, addresses of parents or guardians, x
dates of admission, and placement upon discharge)
Comments/Corrective Actions:
Licensing Coordinator’s Signature: ________________________ Date: _____1_-_1_4_-2_0_2_5_______
Manager Review: ______________________________________ Date: ____1_-_1_4_-_2_0_2_5______
P age 42 | 42
Form Rev. 1/2/2024

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

report_type: License Renewals

visit_date: November 4th - 7th, 2024

program_compliance:
The program was found to be compliant or will be compliant with OAR 419-400-0005 to 419-400-0310, Licensing Umbrella
Rules, OAR 419-430-0010 to 419-430-0110, Licensing Day Treatment Agencies Rules, OAR 419-440-0010 to 419-440-0210, Licensing Foster
Care Agencies Rules and OAR 419-470-0010 to 419-470-0180, Licensing Residential Care Agencies Rules. Personnel records were reviewed and
compliance with required background checks was documented for employees in all programs.
Agency Description provided by Morrison Child & Family Services: Morrison provide a wide array of culturally responsive and trauma-informed
programs. Morrison provides mental health and substance use treatment, services for victims of sex trafficking and many other services. Morrison
Child and Family Services was founded by a group of concerned citizens and physicians committed to providing mental health services for
children in the community. Dr. Carl Morrison, one of Oregon's first child psychiatrists, served as Morrison's first

funding_sources: Mi Futuro & LTGH - U.S. Health and Human Services (HHS) Office of Refugee Resettlement (ORR), Oregon Department of Human Services (ODHS), Oregon Health Authority (OHA) Contracts: ORR Residential Shelter Services, ORR Residential LTGH Services Residential Care and Support for victims of Trafficking and Commercial Sexual Exploitation (CSEC) population Sources for referrals: Federal Field Specialists, Parent/Guardians, ODHS Case Workers, OYA Probation and Parole Officers.

average_length_of_stay: The

average_daily_population_served: The average daily population was identified by program managers. Planned Crisis Respite Foster Care: - 2023- 38 children - 2024- 24 children Counterpoint foster care: - 2023- 13 children - 2024- 11 children SAGE residential care: - 2023-11 children - 2024- 17 children Residential Care Program Update-Long Term Group Home: - 2023-8 children - 2024-11 children Residential Care Program Update-Shelter: - 2023-19 children - 2024- 15 children

number_of_children_served_annually: Number of children served was identified by program managers. Planned Crisis Respite Foster Care: - 2023- 71 children - 2024- 50 children Counterpoint foster care: P age 5 | 42 - 2023- 32 children - 2024- 16 children SAGE residential care: - 2023-34 children - 2024- 32 children Residential Care Program Update-Long Term Group Home: - 2023-31 children - 2024- 23 children Residential Care Program Update-Shelter: - 2023- 196 children - 2024-165 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: The Downtown Long-Term Group Home and Shelter. SAGE Staff are trained in the Mandt Intervention System. Counterpoint Day Treatment and Morrison Foster Care are "hands off" programs. The staff are trained in NCI's non-physical interventions and de-escalation techniques.

grievances_and_complaints:
Morrison Child and Family Services Foster Care programs address all types of concerns,
complaints, and formal grievances raised by youth, parents, or staff. There were not formal grievances for Mi Futuro, LTGH, or SAGE for either FY
22-23 or FY 23-24. There were 2 total complaints for SAGE, 1 for FY 22-23 and 1 for FY23-24, both complaints were addressed and did not
escalate further. The Counterpoint Day Treatment Program tracks client complaints and grievances as a part of its quality improvement initiatives.
P age 7 | 42

During FY 23 and FY 24 there were no complaints submitted in FY 23 and one complaint was submitted in FY 24. The complaint was resolved
successfully by program staff.

recommendations: No

excerpt:
(c) Suicide prevention and intervention Mi Futuro – 1 file was missing suicide prevention and intervention training for new
employee requirements.
LTGH – 1 file reviewed was missing 2024 suicide prevention and intervention training for
new employees.
Corrective Action:
• Programs will ensure suicide prevention and intervention training for new
employees are completed. The agency will submit it as part of the Corrective
Action Plan.

excerpt:
(e) Training on the agency’s policy on
suicide prevention and suicide risk
assessment tool ORR Programs - 2 out of 4 staff files reviewed did not have any training on this topic
listed. One staff file reviewed had the assessment tool training.
Corrective Action:
• Agency will ensure this requirement is met and submit it as part of the Corrective
Action Plan.

excerpt:
(b) Name and location of previous and
current school SAGE – 5 out of 5 staff files reviewed were missing name and location of previous and
current school.
Corrective Action:
• Program will ensure Name and location of current school is completed in the
summary sheet. Program will submit this as part of their Corrective Action Plan.

excerpt:
Each child caring
agency shall provide notice regarding how to
access the quarterly reports to the parents or
guardians of children in care in the program.
The child caring agency shall provide the Mi Futuro & LTGH - 5 out of 5 records reviewed were missing documentation indicating
the notice regarding how to access the quarterly reports had been provided to the parents
or guardians of children in care in the program. The child caring agency shall provide the
required notice upon the child in care’s admission and at least two times each year
thereafter.

excerpt:
(3)(a) Evacuation drill occurs monthly 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 Program is missing the February 2023 fire drill. It was not
completed.
Corrective Action:
• Program will ensure that all fire drills are completed
monthly and submit this as part of the Corrective
Action Plan.

excerpt:
Each child caring agency shall provide notice
regarding how to access the quarterly reports to the parents or guardians
of children in care in the program. The child caring agency shall provide
the notice upon the child in care’s admission and at least two times each
year thereafter. This required documentation was not found in all records
reviewed.
Corrective Action:
• Program shall provide notice regarding how to
access the quarterly reports to the parents or
guardians of children in care in the program.
Program will submit this as part of the Corrective
Action Plan.

excerpt:
Environmental emergencies 2 out of 4 files reviewed were missing documentation of ongoing
training for Environmental Emergencies.
Corrective Action: