facility_name: Daybreak Youth Services – Spokane Inpatient

report_date: December 30, 2020

summary: State Investigation

raw_content:
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
December 30, 2020
Daybreak Youth Services - Spokane
628 S Cowley St
Spokane,WA 99202-1377
Re: Complaint Investigation
Case Number: 2020-4616, 2020-4617
License Number: BHA.FS.60873305, RTF.FS.00001010
Date(s) of Investigation; 04/13/20 - 12/29/20
Dear Mr. Russell:
The State of Washington Department of Health recently completed an investigation ofDaybreak
Youth Services - Spokane on December 29, 2020.
No current deficiencies were identified during this investigation.
Please retain a copy of this letter for your files.
Thank you for your time and assistance during this investigation.
Investigator: #33894
Department of Health
HSQA/Office of Health Systems Oversight
PO Box 47874
Olympia, Washington 98504-7874


state: WA

summary: State Investigation

raw_content:
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
December 30, 2020
Daybreak Youth Services - Spokane
628 S Cowley St
Spokane,WA 99202-1377
Re: Complaint Investigation
Case Number: 2020-3888, 2020-3890
License Number: RTF.FS.00001010, BHA.FS.60873305
Date(s) of Investigation: 03/10/20 m 12/29/20
Dear Mr. Russell:
The State of Washington Department of Health recently completed an investigation ofDaybreak
Youth Services - Spokane on December 29, 2020.
No current deficiencies were identified during this investigation.
Please retain a copy of this letter for your files.
Thank you for your time and assistance during this investigation.
Investigator: #33894
Department of Health
HSQA/Office of Health Systems Oversight
PO Box 47874
Olympia, Washington 98504-7874


summary: State Investigation

raw_content:
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
December 30, 2020
Daybreak Youth Services - Spokane
628 S Cowley St
Spokane,WA 99202-1377
Re: Complaint Investigation
Case Number: 2020-4631, 2020-4632
License Number: RTF.FS.00001010, BHA.FS.60873305
Date(s) of Investigation: 04/13/20 - 12/29/20
Dear Mr. Russell:
The State of Washington Department of Health recently completed an investigation ofDaybreak
Youth Services - Spokane on December 29, 2020.
No current deficiencies were identified during this investigation.
Please retain a copy of this letter for your files.
Thank you for your time and assistance during this investigation.
Investigator: #33894
Department of Health
HSQA/Office of Health Systems Oversight
PO Box 47874
Olympia, Washington 98504-7874


facility_name: Newport Academy

report_date: February 21, 2025

summary: State Inspection — ONGOING - ROUTINE (01/29/25)

raw_content:
Behavioral Health Agency Inspection Report
Department of Health
P.O. Box 47874, Olympia, WA 98504-7874
TEL: 360-236-4732
February 21, 2025
Newport Academy, 3804 Hastings Ave W, Port Townsend, WA. 98368-9642 Michael Tyers
Agency Name and Address Administrator
ONGOING - ROUTINE 01/29/25 ECR03
Inspection Type Inspection Onsite Dates Inspector
X2025-67 BHA.FS.60957239
Inspection Number License Number
Please note that the deficiencies/violations/observations noted in this report are not all-inclusive, but rather were deficiencies/violations/observations that were
observed or discovered during the on-site inspection.
During the inspection, the following complaint was reviewed: 2025-239.
Deficiency Number and Rule Reference Observation Findings Plan of Correction
0675 Personnel-Agency record requirements Based on interview, policy and procedure review, and 0675 Personnel-Agency record
WAC 246-341-0510(1)(a) A behavioral health agency personnel record review, the agency failed to ensure all staff requirements
must maintain a personnel record for each person had a signed position description in the personnel records. WAC 246-341-0510(1)(a) Deficiency
employed by the agency. (1) The personnel record will be corrected as followed: Human
must contain all of the following: (a) A signed position Failure to ensure a signed position description in the Resources is responsible for
description. personnel file can lead to missed staff responsibilities and can implementing this correction. Effective
lead to client harm. 3/3/2025, Human Resources has
confirmed signed position description
Findings included: in staff personnel files. Human
Resources will complete monthly audit
1. Review of the personnel records for Staff G, Care reports to ensure all new and current
Coordinator, showed that there was no signed position employees have signed position
description in their personnel file. descriptions in staff files.
2. During an interview with Staff I, Human Resources (HR)
Generalist, on 01/29/25 at 01:00 PM, they stated, “It looks
like we do not have a signed position description.”
3. Review of the policies and procedures titled, “Agency
Personnel Record Requirements”, updated 11/01/23, states
the agency will maintain a current, signed job description for
all staff.
0730 Personnel-Agency record requirements Based on interview, policy and procedure review, and 0730 Personnel-Agency record
WAC 246-341-0510(1(f) A behavioral health agency personnel record review, the agency failed to ensure all staff requirements
must maintain a personnel record for each person had a copy of their current credential in the personnel WAC 246-341-0510(1(f) Deficiency will
employed by the agency. (1) The personnel record records. be corrected as followed: Human
must contain all of the following: (f) A copy of the Resources is responsible for
staff member's valid current credential issued by the Failure to ensure staff are credentialed may lead to poor implementing this correction. Effective
department if they provide clinical services. client outcomes. 3/3/2025, Human Resources has
confirmed all new and current clinical
Findings included: team members have current
credentials in personnel files. Human
1. Review of the personnel records for Staff D, Clinical Resources will complete monthly audit
Director, showed there was no record of a current credential reports to ensure all new and current
in the personnel record. clinical team members have current
2. During an interview with Staff I, Human Resources (HR) credentials in staff personnel files.
Generalist, on 01/29/25 at 01:00 PM, they verified there was
no record of a current credential in the personnel record and
stated, “I am not seeing [their] most current one in the file.”
3. Review of the policies and procedures titled, “Agency
Personnel Record Requirements”, updated 11/01/23, states
the personnel record must have a copy of the staff member's
valid current credential issued by the department if they
provide clinical services.
0925 Individual service record content Based on clinical record review and interview, the agency 0925 Individual service record
WAC 246-341-0640(1)(a) A behavioral health agency failed to provide documentation that individuals received a content
is responsible for the components and copy of counselor disclosure requirements as required for the WAC 246-341-0640(1)(a)
documentation in an individual's individual service counselor credential for 4 of 4 clinical records reviewed Deficiency will be corrected as
record content unless specified otherwise in (Client #1-#4). followed: Discharge Letters are
certification or individual service requirements. (1) signed and provided to each
The individual service record must include: (a) Failure to ensure all clients receive the counselor disclosure client upon discharge. We have
Documentation the individual received a copy of requirements and show documentation in the clinical record submitted a request to our EHR to
counselor disclosure requirements as required for the may result in clients not choosing counselors who best suit add in a field for treatment team
counselor's credential. names and credentials on this letter.
their needs and can result in poor client outcomes.
Findings included:
1. Review of the clinical record for Client #1, Client #2, Client
#3, and Client #4 showed they did not contain a counselor
disclosure as required for the counselor’s credential.
2. During an interview with Staff E, Administrator, on
12/03/24 at 2:28 PM, they stated, “We have it on the wall,
just not a detailed copy for the clients.”
Introduction
We require that you submit a plan of correction for each deficiency listed on the inspection report form. Your plan of correction must be
submitted to the DOH within ten business days of receipt of the list of deficiencies.
Descriptive Content
Your plan of correction must provide a step-by-step description of the methods to correct each deficient practice to prevent recurrence and
provide information that ensures the intent of the regulation is met.
An acceptable plan of correction must contain the following elements:
• The plan of correcting the specific deficiency;
• The procedure for implementing the acceptable plan of correction for the specific deficiency cited;
• The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and/or in
compliance with the regulatory requirements;
• The title of the person responsible for implementing the acceptable plan of correction.
Simply stating that a deficiency has been "corrected" is not acceptable. If a deficiency has already been corrected, the plan of correction must
include the following:
• How the deficiency was corrected,
• The completion date (date the correction was accomplished),
• How the plan of correction will prevent possible recurrence of the deficiency.
Completion Dates
The POC must include a completion date that is realistic and coinciding with the amount of time your facility will need to correct the deficiency.
Direct care issues must be corrected immediately and monitored appropriately. Some deficiencies may require a staged plan to accomplish total
correction. Deficiencies that require bids, remodeling, replacement of equipment, etc., may need more time to accomplish correction; the target
completion date, however, should be within a reasonable and mutually agreeable time-frame.
Continued Monitoring
Each plan of correction must indicate the appropriate person, either by position or title, who will be responsible for monitoring the correction of
the deficiency to prevent recurrence.
Checklist:
• Before submitting your plan of correction, please use the checklist below to prevent delays.
• Have you provided a plan of correction for each deficiency listed?
• Does each plan of correction show a completion date of when the deficiency will be corrected?
• Is each plan descriptive as to how the correction will be accomplished?
• Have you indicated what staff position will monitor the correction of each deficiency?
• If you included any attachments, have they been identified with the corresponding deficiency number or identified with the page number to
which they are associated?
Your plan of correction will be returned to you for proper completion if not filled out according to these guidelines.
Note: Failure to submit an acceptable plan of correction may result in enforcement action.
Approval of POC
Your submitted POC will be reviewed for adequacy by DOH. If your POC does not adequately address the deficiencies in your inspection report you
will be sent a letter detailing why your POC was not accepted.
Questions?
Please review the cited regulation first. If you need clarification, or have questions about deficiencies you must contact the inspector who
conducted the onsite inspection, or you may contact the supervisor.
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
3/19/2025
Newport Academy
3804 Hastings Ave W
Port Townsend, WA 98368-9642
Re: Exam Number: X2025-67
License Number: BHA.FS.60957239
Approved Plan of Correction
Date(s) of Inspection: 01/29/25
Dear Administrator:
This letter is to inform you that after careful review of the Plan of Correction (POC) you
submitted for the exam recently conducted at your facility, the Department has determined that
the POC is approved.
Based on the scope and severity of the deficiencies listed in your statement of deficiency report,
the Department will not conduct an announced follow-up compliance visit to verify that all
deficiencies have been corrected.
Reviewer: ECR03
Department of Health
HSQA/Office of Health Systems Oversight
PO Box 47874
Olympia, Washington 98504-7874

report_type: Inspection Report

inspection_type: ONGOING - ROUTINE

administrator: Michael Tyers


report_date: September 29, 2022

summary: State Inspection — ONGOING - ROUTINE (09/28/2022)

raw_content:
Behavioral Health Agency Inspection Report
Department of Health
P.O. Box 47874, Olympia, WA 98504-7874
TEL: 360-236-4732
September 29, 2022
Newport Academy, 3804 Hastings Ave W, Port Townsend, WA.
98368-9642 Michael Tyers
Agency Name and Address Administrator
ONGOING - ROUTINE 09/28/2022 RXE03
Inspection Type Inspection Onsite Dates Inspector
X2022-374 BHA.FS.60957239
Inspection Number License Number
Please note that the deficiencies/violations/observations noted in this report are not all-inclusive, but rather were deficiencies/violations/observations
that were observed or discovered during the on-site inspection.
Deficiency Number and Rule Reference Observation Findings Plan of Correction
0910 Clinical record content The Washington Administrative Code (WAC) is not met
Counselor Disclosure form included.
WAC 246-341-0640(1)(a) Each agency is as evidenced by:
All clients will sign this upon
responsible for the components and
Based on clinical record review, policies, and
admission.
documentation in an individual's clinical record
procedures (P&P) review and staff interview, it was
content unless specified otherwise in specific
determined the agency failed to ensure each resident Program Manager does spot audits
service certification requirements. (1) The
received a copy of the counselor disclosure to make sure all consents are being
clinical record must include: (a) Documentation
requirements in accordance with MH/A WAC signed.
the individual received a copy of counselor
246-810-031 Disclosure Statement content for 4 of 4
disclosure requirements as required for the
records reviewed. Compliance Department completed
counselor's credential.
monthly audits.
Reference: SUDP/T WAC 246-811-90
A substance use disorder professional and a
substance use disorder professional trainee must
provide client disclosure information.
A substance use disorder professional and a
substance use disorder professional trainee must
provide disclosure information to each client prior to
the delivery of certified services. Disclosure
information may be printed in a format of the
substance use disorder professional's choosing or in
a general format used by a state approved treatment
facility.
Reference: SUDP/T WAC 246-811-100
Disclosure statement requirements.
(1)The following information must be
printed on all disclosure statements provided to
counseling clients in language that can be
easily understood by the client:
(a) Name of firm, agency, business, or
substance use disorder professional's practice.
(b) Employment address and telephone
number.
(c) Name, credential, and credential
number.
(d) Billing information, including:
(i) Client's cost per each counseling
session;
(ii) Billing practices, including any
advance payments and refunds.
(e)A list of the acts of unprofessional
0935 Clinical record content Washington Administrative Code is not met as Licensing and Compliance Manager
WAC 246-341-0640(1)(c)(iv) Each agency is evidence by: is working with Electronic Health
responsible for the components and Record developers to build specific
documentation in an individual's clinical record
ASAM Dimensions into the Pre-
content unless specified otherwise in specific Based on clinical record review, P&P review, and staff
Admission Assessment (VAIR), this
service certification requirements. (1) The interview, it was determined the agency failed to
will be filled out if the client is given a
clinical record must include: (c) An assessment document a diagnostic assessment statement
primary substance use diagnosis
which is an age-appropriate, strengths-based supported by. the current and applicable American
during the clinical clearance process.
psychosocial assessment that considers current Psychiatric Association: Diagnostic and Statistical
This should be released for use
needs and the individual's relevant behavioral Manual of Mental Disorders, Fifth Edition. Arlington, VA,
within the next 30-45 days.
and physical health history according to best American Psychiatric Association, 2013. (DSM-5).
practices, completed by a person appropriately
In the meantime, clinicians complete
credentialed or qualified to provide the type of The agency failed to document placement decision
the clinical clearance have been
assessment pertaining to the service(s) being using ASAM criteria dimensions, when the
trained to documents ASAM criteria
sought, which includes: (iv) A diagnostic assessment indicates the individual is in need of
for any client with a primary
assessment statement, including sufficient substance use disorder services.
substance use diagnosis.
information to determine a diagnosis supported
Failure to ensure that a diagnostic assessment
by the current and applicable Diagnostic and
In the new form, the user is already
statement includes sufficient data to determine a
Statistical Manual of Mental Disorders (DSM-5)
prompted to write a clinical case
diagnosis supported by the (DSM-5) may result in
or a placement decision, using ASAM criteria
conceptualization summary and
dimensions, when the assessment indicates the inaccurate diagnosis as well as an inaccurate level of
symptoms to support DSM-V
individual is in need of substance use disorder care recommendation for treatment services.
diagnosis.
services.
Failure to ensure the ASAM criteria is used in making
placement decisions places residents at risk of not Our National Clinical Team team
receiving the appropriate level of care for treatment does periodic audits of Clinical
services. Clearances to ensure correct
rationale is being given for the level
Reference: The ASAM Criteria, Treatment
of care the client is admitted to and
Criteria for Addictive, Substance-Related, and
that there are specifics to support
Co-Occurring Conditions, American Society of
the given diagnosis.
Addiction Medicine, Third Edition, 2013, Page
110.
“The ASAM criteria multidimensional
assessment helps ensure comprehensive
treatment. In the process of patient assessment,
certain problems and priorities are identified as
justifying admission to a particular level of care.
The resolution of those problems and priorities
determines when a patient can be treatment at
a different level of care or discharged from
treatment. The appearance of new problems
0975 Clinical record content The Washington Administrative Code (WAC) was not Licensing and Compliance Manager
WAC 246-341-0640(1)(g) Each agency is met as evidenced by: is working with Electronic Health
responsible for the components and Based on clinical record review, P&P review, and staff Record developers to build specific
documentation in an individual's clinical record interview, it was determined the agency failed to ASAM Dimensions into the Pre-
content unless specified otherwise in specific document in clinical records a review of ASAM Admission Assessment (VAIR), this
service certification requirements. (1) The dimensional criteria to determine the need for will be filled out if the client is given
clinical record must include: (g) If treatment is continued services at the same level of care or a review a primary substance use diagnosis
for a substance use disorder, documentation of progress and changing to a lower level of care. during the clinical clearance
that ASAM criteria was used for admission, process. This should be released
continued services, referral, and discharge The ASAM Criteria, Treatment Criteria for Addictive, for use within the next 30-45 days.
planning and decisions. Substance-Related, and Co-Occurring Conditions,
American Society of Addiction Medicine, Third Edition In the meantime, clinicians
(ASAM). complete the clinical clearance
Reference: Mee-Lee D, Shulman GD, Fishman have been trained to documents
MH, Gastfirend DR, Miller MM, eds. The ASAM ASAM criteria for any client with a
Criteria: Treatment Criteria for Addictive, primary substance use diagnosis.
Substance-Related, and Co-Occurring Clinical Director, Nina Foster will
rd monitor this.
Conditions. 3 ed. Carson City, NV: The
Change Companies©; 2013. Page 110.
“The ASAM criteria multidimensional Our National Clinical Team team
assessment helps ensure comprehensive does periodic audits of Clinical
treatment. In the process of patient assessment, Clearances to ensure correct
certain problems and priorities are identified as rationale is being given for the level
justifying admission to a particular level of care. of care the client is admitted to and
The resolution of those problems and priorities that there are specifics to support
determines when a patient can be treatment at the given diagnosis.
a different level of care or discharged from
treatment. The appearance of new problems
may require services that can be effectively
provided at the same level of care, or that
require a more or less intensive level of care. As
the patient’s response to treatment is assessed,
new priorities for recovery are identified…At
such time, changing the level of care or
changing the program should be based upon a
reassessment of the treatment plan with
modifications to achieve a better therapeutic
response. In cases where some extenuating
circumstances must be considered, further
justification and presentation of rationale should
Introduction
We require that you submit a plan of correction for each deficiency listed on the inspection report form. Your plan of correction must be
submitted to the DOH within ten business days of receipt of the list of deficiencies.
Descriptive Content
Your plan of correction must provide a step-by-step description of the methods to correct each deficient practice to prevent recurrence
and provide information that ensures the intent of the regulation is met.
An acceptable plan of correction must contain the following elements:
• The plan of correcting the specific deficiency;
• The procedure for implementing the acceptable plan of correction for the specific deficiency cited;
• The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected
and/or in compliance with the regulatory requirements;
• The title of the person responsible for implementing the acceptable plan of correction.
Simply stating that a deficiency has been "corrected" is not acceptable. If a deficiency has already been corrected, the plan of
correction must include the following:
• How the deficiency was corrected,
• The completion date (date the correction was accomplished),
• How the plan of correction will prevent possible recurrence of the deficiency.
Completion Dates
The POC must include a completion date that is realistic and coinciding with the amount of time your facility will need to correct the
deficiency. Direct care issues must be corrected immediately and monitored appropriately. Some deficiencies may require a staged plan
to accomplish total correction. Deficiencies that require bids, remodeling, replacement of equipment, etc., may need more time to
accomplish correction; the target completion date, however, should be within a reasonable and mutually agreeable time-frame.
Continued Monitoring
Each plan of correction must indicate the appropriate person, either by position or title, who will be responsible for monitoring the
correction of the deficiency to prevent recurrence.
Checklist:
• Before submitting your plan of correction, please use the checklist below to prevent delays.
• Have you provided a plan of correction for each deficiency listed?
• Does each plan of correction show a completion date of when the deficiency will be corrected?
• Is each plan descriptive as to how the correction will be accomplished?
• Have you indicated what staff position will monitor the correction of each deficiency?
• If you included any attachments, have they been identified with the corresponding deficiency number or identified with the page
number to which they are associated?
Your plan of correction will be returned to you for proper completion if not filled out according to these guidelines.
Note: Failure to submit an acceptable plan of correction may result in enforcement action.
Approval of POC
Your submitted POC will be reviewed for adequacy by DOH. If your POC does not adequately address the deficiencies in your
inspection report you will be sent a letter detailing why your POC was not accepted.
Questions?
Please review the cited regulation first. If you need clarification, or have questions about deficiencies you must contact the inspector
who conducted the onsite inspection, or you may contact the supervisor.
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
PO Box 47874 • Olympia, Washington 98504-7874
November 17, 2022
Crystal Goodwin, Regional License Compliance Manager
Newport Academy
3804 Hastings Ave W
Port Townsend, WA 98368
Dear Ms. Goodwin:
The Washington State Department of Health conducted an inspection at Newport
Academy - 3804 Hastings Ave W - Port Townsend, WA 98368
Your inspection was conducted on September 29, 2022. The Plan of Correction that
was submitted on November 17, 2022, was approved on November 17, 2022. No
further action is required.
I sincerely appreciate your cooperation and hard work during the inspection process
and look forward to working with you again in the future.
Sincerely,
Rosa Elvia, SUDP
Behavioral Health Reviewer


summary: State Investigation

raw_content:
Statement of Deficiency Report
Department of Health
P.O. Box 47874, Olympia, WA 98504-7874
TEL: 360-236-4732
Newport Academy 3804 Hastings Avenue West Port Townsend, WA
98368 Crystal Goodwin
Agency Name and Address Administrator
Investigation Tuesday, April 12, 2022 42124
Inspection Type Investigation Start Date Investigator Number
2022-3096 BHA.FS.60957239 BHA inpatient
Case Number License Number BHA/RTF Agency Services Type
Please note that the deficiencies/violations/observations noted in this report are not all-inclusive, but rather were deficiencies/violations/observations that were
observed or discovered during the investigation.
Deficiency Number and Rule Reference Findings Plan of Correction
WAC 246-341-0420 (13)(a), Agency policies and Based on staff interview and policy and procedure Compliance Manager, Crystal
procedures. Each agency licensed by the review, the agency failed to ensure that they followed Goodwin, completed training with
department to provide any behavioral health their policy to report to the department within 48 hours newly onboarded Executive
service must develop, implement, and maintain any critical incident that occurred to an individual for 1 Director, Interim Executive Director
policies and procedures that address all of the of 4 patients reviewed (Patient #3). and Residential Manager on
applicable licensing and certification reporting requirements in line with
requirements of this chapter including Failure to report critical incidents to the department can WAC 246-341-0420. Moving
administrative and personnel policies and lead to poor patient outcomes. forward, the Executive Director will
procedures. Administrative polices and be responsible for reporting any
procedures must demonstrate the following, as Findings included: instances of abuse to the
applicable: (13) Reporting critical incidents. A Department of Health.
description of how the agency directs staff to
report to the department within forty-eight 1. During an interview on 04/12/22 at 1:00 PM, Staff A,
hours any critical incident that occurs involving Licensing and Compliance Manager, stated that the
an individual, and actions taken as a result of the alleged sexual assault incident was only reported to the
incident. A critical incident is a serious or Department of Children, Youth and Family (DCYF) and
undesirable outcome that occurs in the agency was not reported to DOH. Staff A was not aware that
including: (a) Allegations of abuse, neglect or this should have been reported to the Department of
exploitation Health.
2. Review of the policy titled, “Completing and
Submitting Reports”, revised 01/01/21 showed that the
agency would “complete and submit reports in
accordance with WAC 246-341-0420 (13).”
3. Review of the policy titled, “Reporting Critical
Incidents Involving Individuals”, revised 01/01/21,
showed that “serious or undesirable outcomes” must be
reported to DOH by the end of the next business day.
Critical Incidents included “sexual contact between
clients.”
WAC 246-341-0600, (3)(a) Clinical – Individual Based on staff interview and policy and procedure Compliance Manager, Crystal
rights. (3) Each agency must ensure the review, the agency failed to provide patient rights to 1 Goodwin, completed training with
applicable individual participant rights described of 4 patients reviewed (Patient #3). all Residential Supervisors on
in subsection (1) of this section are: (a) Provided consents during the admission
in writing to each individual on or before Findings included: process. We discussed the process
admission for generating consents, protocols
1. Review of the policy titled, "Individual Rights", revised and timelines, what to do when a
01/01/21, showed that the patient rights would be client refuses to sign consents and
posted in a central location and would be reviewed with any additional questions.
all patients upon admission. The procedure showed that
all patients and parents or guardians are provided a
copy of the rights upon admission.
2. During an email exchange between the Investigator
and Staff A, Licensing and Compliance Manager, on
04/25/22 at 5:16 PM, Staff A stated they were unable to
locate signed patient rights for Patient #3.
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
May 25, 2022
Newport Academy
3804 Hastings Ave. West
Port Townsend, WA 98368
Re: Case Number: 2022-3096 BHA
License Number: BHA.FS.60957239
Acceptable Plan of Correction
Date of Survey: April 12, 2022
Dear Administrator:
This letter is to inform you that after careful review of the Plan of Correction (POC) you
submitted for the investigation recently conducted at your facility, the Department has
determined that the POC is acceptable. You stated in your plan that you will implement
corrective actions by the specified timeline. By this, the Department is accepting your Plan of
Correction as your confirmation of compliance.
Based on the scope and severity of the deficiencies listed in your statement of deficiency report,
the Department will not conduct an unannounced follow-up compliance visit to verify that all
deficiencies have been corrected. Any fees that may be enforced based on the results of the
investigation will be implemented consistent with WAC 246-341-0365 and WAC 246-337-990
In addition, the Department reserves the right to pursue enforcement action for any repeat and/or
uncorrected deficiencies based on applicable statute and rules.
Please feel free to contact me at the email address you have on file if you have questions
regarding the investigation.
The survey team sincerely appreciates your cooperation and hard work during the investigation.
Sincerely,
Investigator 42124
Behavioral Health Investigator
Health Services Consultant 4

report_type: Report

administrator: Crystal Goodwin


summary: State Investigation

raw_content:
Statement of Deficiency Report
Department of Health
P.O. Box 47874, Olympia, WA 98504-7874
TEL: 360-236-4732
Newport Academy 3804 Hastings Avenue West Port Townsend, WA
98368 Crystal Goodwin
Agency Name and Address Administrator
Investigation Tuesday, April 12, 2022 42124
Inspection Type Investigation Start Date Investigator Number
2022-3097 RTF.FS.60957241 RTF inpatient
Case Number License Number BHA/RTF Agency Services Type
Please note that the deficiencies/violations/observations noted in this report are not all-inclusive, but rather were deficiencies/violations/observations that were
observed or discovered during the investigation.
Deficiency Number and Rule Reference Findings Plan of Correction
WAC 246-337-075 (2)(a)(g) Resident rights. The Based on staff interview, root cause analysis review, As noted in the RCA, Interim
licensee must establish a process to ensure policy and procedure review, and patient clinical Executive Director, Kristina
resident rights are protected in compliance with document review, the agency failed to ensure patients Schemnitzer, implemented the
chapter 71.12 RCW, this chapter, and other were free from abuse and failed to ensure they had a following
applicable laws, and are based on the service safe environment for 4 of 4 patients reviewed (Patient • Daily safety walkthroughs
types provided in the RTF. This process must #1, #2, #3, and #4). which included
address how the RTF will: (2) Treat each resident environmental safety checks
in a manner that respects individual identity, Failure to ensure patients are free from abuse and have as well as an increased
human dignity and fosters constructive self- a safe environment can lead to poor patient outcomes supervision beginning
esteem. Each resident has the right to: (a) Be and create long term traumas. 3/4/22
free of abuse, including being deprived of food,
Findings included:
clothes or other basic necessities; (g) Have a safe 1. During an interview on 04/12/22 at 1:00 PM, Staff A, • Ongoing live, in the moment
and clean environment. Licensing and Compliance Manager, stated that patients coaching and training for all
“are supervised at all times…we do regular checks.” Staff staff
A stated that the patients supervised at all times means • Sent out program-wide
that they are within eyesight- but not line of sight or one email about safety and
to one. Staff A stated that, “they just can’t roam around supervision
campus and do whatever they want.” Staff A stated that • Local Leadership
there are 15-minute checks at night. implemented culture of
accountability around client
2. Review of the document titled, "Facility Rules & supervision
Guidelines", undated, showed that facility rules included • Training on supervision
the following: "Residents are not allowed in other completed with all staff in 2
resident's bedrooms at any time; residents must be in meetings on 3/31/22
their own bedroom at the designated 'lights out' time; • Increased frequency of
residents may be asked to leave bedroom door ajar…" accountability feedback and
During an email exchange between the Investigator and
disciplinary action for those
Staff A on 04/28/22 at 9:53 AM, Staff A stated that these staff who do not follow
rules were provided to all patients in the handbook
supervision protocols
upon admission.
• Hired additional staff to
have available in the event
3. Review of the “Root Cause Analysis”, dated 03/07/22,
of staffing shortages on
showed that Patient #3 had gone into the room of
shifts/call offs
Patient #1, #2 and #4 on the night of the alleged sexual
assault incident. Incident documentation showed the
patients stated that the case manager "was lenient and
allowed clients to be in each other's bedrooms."
4. Review of the “Root Cause Analysis” document
showed that Patient #3 reported that “2 peers held
[them] down and a 3rd peer rubbed [their] private parts
on [their] face”. The patient stated they called for help
but felt like no one could hear [them].
5. Review of the “Root Cause Analysis” document
showed that Patients #1, #2, and #4, were interviewed.
Patient #2 denied everything; it was discovered through
patient interviews that Patient #1 and #4 held Patient #3
down while Patient #2 rubbed their genitals on Patient
#3's face.
6. Review of the section in the “Root Cause Analysis”
titled, "Analysis" showed that the “policy for supervision
of the patients was not followed”, and staff were
permitting patients to be in one another's rooms.
WAC 246-337-075 (3) Resident rights. The Based on staff interview and policy and procedure Upon investigation, it was
licensee must establish a process to ensure review, the agency failed to provide patient rights to 1 determined that Patient #3 refused
resident rights are protected in compliance with of 4 patients reviewed (Patient #3). to sign consents. This was verbally
chapter 71.12 RCW, this chapter, and other confirmed by Residential Supervisor
applicable laws, and are based on the service Failure to ensure that patient rights are provided upon
types provided in the RTF. This process must admission can lead to poor patient outcomes. Compliance Manager, Crystal
address how the RTF will: (3) On or before Goodwin, completed training with
admission, document that each resident, or the Findings included: all Residential Supervisors on
resident’s personal representative, designee, 5/25/22 covering consent process
parent or guardian receives a written copy of the 1. Review of the policy titled, "Individual Rights", revised during the admission process. We
resident’s rights that includes all items in 01/01/21, showed that the patient rights would be discussed the process for
subsection (2) of this section. posted in a central location and would be reviewed with generating consents, protocols and
all patients upon admission. The procedure showed that timelines, how to document when a
all patients and parents or guardians are provided a client refuses to sign consents and
copy of the rights upon admission. any additional questions.
2. During an email exchange between the Investigator
and Staff A, Licensing and Compliance Manager, on
04/25/22 at 5:16 PM, Staff A stated they were unable to
locate signed patient rights for Patient #3.
WAC 246-337-065 (5)(a) Safety and Security. The Based on staff interview, the agency failed to report to Compliance Manager, Crystal
licensee must protect resident safety and the Department of Health an incident of sexual abuse Goodwin, completed training with
security by developing written policies and for 1 or 4 patients reviewed (Patient #3). newly onboarded Executive
procedures that are consistent with the Director, Interim Executive Director
requirements of this chapter and address: (5) Failure to report incidents of abuse to the department and Residential Manager on
Reporting to the department and other within the reporting times can result in poor patient reporting requirements in line with
appropriate agencies, by the end of the next outcomes. WAC 246-337-065. Moving forward,
business day of the incident occurring, serious or the Executive Director will be
undesirable outcomes that occur in the facility Findings included: responsible for reporting any
including: (a) Allegations of abuse. instances of abuse to the
1. During an interview on 04/12/22 at 1:00 PM, Staff A, Department of Health.
Licensing and Compliance Manager, stated that the
alleged sexual assault incident was only reported to the
Department of Children, Youth and Family (DCYF) and
was not reported to DOH. Staff A was not aware that
this should have been reported to the Department of
Health.
Plan of Correction Instructions
Introduction
We require that you submit a plan of correction for each deficiency listed on the statement of deficiency form. Your plan of correction must be
Submitted to DOH within fourteen calendar days of receipt of the list of deficiencies.
You are required to respond to the statement of deficiencies by submitting a plan of correction (POC). Be sure to refer to the deficiency number. If
you include exhibits, identify them and refer to them as such in your POC.
Descriptive Content
Your plan of correction must provide a step-by-step description of the methods to correct each deficient practice to prevent recurrence and
provide information that ensures the intent of the regulation is met.
An acceptable plan of correction must contain the following elements:
• The plan of correcting the specific deficiency;
• The procedure for implementing the acceptable plan of correction for the specific deficiency cited;
• The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and/or in
compliance with the regulatory requirements;
• The title of the person responsible for implementing the acceptable plan of correction.
Simply stating that a deficiency has been "corrected" is not acceptable. If a deficiency has already been corrected, the plan of correction must
include the following:
• How the deficiency was corrected,
• The completion date (date the correction was accomplished),
• How the plan of correction will prevent possible recurrence of the deficiency.
Completion Dates
The POC must include a completion date that is realistic and coinciding with the amount of time your facility will need to correct the deficiency.
Direct care issues must be corrected immediately and monitored appropriately. Some deficiencies may require a staged plan to accomplish total
correction. Deficiencies that require bids, remodeling, replacement of equipment, etc., may need more time to accomplish correction; the target
completion date, however, should be within a reasonable and mutually agreeable time-frame.
Continued Monitoring
Each plan of correction must indicate the appropriate person, either by position or title, who will be responsible for monitoring the correction of
the deficiency to prevent recurrence.
Checklist:
• Before submitting your plan of correction, please use the checklist below to prevent delays.
• Have you provided a plan of correction for each deficiency listed?
• Does each plan of correction show a completion date of when the deficiency will be corrected?
• Is each plan descriptive as to how the correction will be accomplished?
• Have you indicated what staff position will monitor the correction of each deficiency?
• If you included any attachments, have they been identified with the corresponding deficiency number or identified with the page number to
which they are associated?
Your plan of correction will be returned to you for proper completion if not filled out according to these guidelines.
Note: Failure to submit an acceptable plan of correction may result in enforcement action.
Approval of POC
Your submitted POC will be reviewed for adequacy by DOH. If your POC does not adequately address the deficiencies, you will be sent a letter
detailing why your POC was not accepted.
Questions?
Please review the cited regulation first. If you need clarification or have questions about deficiencies, you must contact the investigator who
conducted the investigation.
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
May 25, 2022
Newport Academy
3804 Hastings Ave. West
Port Townsend, WA 98368
Re: Case Number: 2022-3097 RTF
License Number: BHA.FS.60957241
Acceptable Plan of Correction
Date of Survey: April 12, 2022
Dear Administrator:
This letter is to inform you that after careful review of the Plan of Correction (POC) you
submitted for the investigation recently conducted at your facility, the Department has
determined that the POC is acceptable. You stated in your plan that you will implement
corrective actions by the specified timeline. By this, the Department is accepting your Plan of
Correction as your confirmation of compliance.
Based on the scope and severity of the deficiencies listed in your statement of deficiency report,
the Department will not conduct an unannounced follow-up compliance visit to verify that all
deficiencies have been corrected. Any fees that may be enforced based on the results of the
investigation will be implemented consistent with WAC 246-341-0365 and WAC 246-337-990
In addition, the Department reserves the right to pursue enforcement action for any repeat and/or
uncorrected deficiencies based on applicable statute and rules.
Please feel free to contact me at the email address you have on file if you have questions
regarding the investigation.
The survey team sincerely appreciates your cooperation and hard work during the investigation.
Sincerely,
Investigator 42124
Behavioral Health Investigator
Health Services Consultant 4


summary: State Investigation

deficiencies: WAC 246-337-080 Resident care services. At Newport Academy Port Townsend/ if a Nurse is not available for a med pass shift/ CC staff will participate in medication observation. The RN nurse manager is available by phone 24 hours a day/ 7 days a week at this location if any issues arise on site. In response to Citation in reference of: WAC 246-337-105 Medication management. In the absence of Nursing staffing during medication pass, trained CC staff will do medication observation.


facility_name: Newport Academy - Axis

report_date: October 17, 2023

summary: State Inspection

raw_content:
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
PO Box 47874  Olympia, Washington 98504-7874
No Deficiencies Found
October 17, 2023
David Laxton
Newport Academy - Axis
19200 Von Karman Ave Ste 500
Irvine, CA 92612-8513
Subject: Inspection Number: X2022-892
License Number: BHA.FS.61185845-BRNCH
Inspection Type: ONGOING - ROUTINE
Dear Mr. David Laxton
This document contains information regarding the recent inspection of Newport Academy - Axis, 4040
Lake Washington Blvd NE Ste 201, Kirkland, WA. 98033-7874 by the Washington State Department
of Health. Your state licensing inspection was completed on 04/03/2023.
During the inspection, no deficient practice was found.
Please contact me if there are questions regarding the inspection process. I may be reached at (360)
236-4690. I am also available by email at Jennifer.Ross@doh.wa.gov.
I want to extend another “thank you” to you and to everyone that assisted me during the survey.
Sincerely,
JMR43
Reviewer


facility_name: Newport Academy - Seattle

report_date: January 31, 2025

summary: State Inspection — ONGOING - ROUTINE (12/03/24)

raw_content:
Behavioral Health Agency Inspection Report
Department of Health
P.O. Box 47874, Olympia, WA 98504-7874
TEL: 360-236-4732
January 31, 2025
Newport Academy - Seattle, 12029 113th Ave NE, Kirkland, WA. 98034-6901 David Laxton
Agency Name and Address Administrator
ONGOING - ROUTINE 12/03/24 ECR03
Inspection Type Inspection Onsite Dates Inspector
X2024-958 BHA.FS.61015899
Inspection Number License Number
Please note that the deficiencies/violations/observations noted in this report are not all-inclusive, but rather were deficiencies/violations/observations that were
observed or discovered during the on-site inspection.
Deficiency Number and Rule Reference Observation Findings Plan of Correction
0705 Personnel-Agency record requirements Based on interview and personnel record review, the 0705 Personnel-Agency record
WAC 246-341-0510(1)(c)(v) A behavioral agency failed to ensure all staff had initial violence requirements
health agency must maintain a personnel prevention training in the personnel record. WAC 246-341-0510(1)(c)(v)
record for each person employed by the Deficiency will be corrected as
agency. (1) The personnel record must contain Failure to ensure timely training may result in client followed:
all of the following: (c) A record of an harm. Human Resources will perform
orientation to the agency within 90 days of hire monthly audits on staff initial
that includes all of the following: (v) Violence Findings included: violence prevention trainings in
prevention training on the safety and violence the personnel record and provide
prevention topics described in RCW 1. Review of the personnel record for Staff A, Mental findings to Residential Leadership
49.19.030. Health Clinical Supervisor, and Staff B, Team (Program Manager,
Administrative Assistant, showed that there was no Executive Director, Clinical
initial violence prevention training in their personnel Director). All initial violence
file. prevention trainings are
completed within the first 30 days
for all new hires. Initial violence
2. During an interview with Staff E, Human Resources prevention trainings are
(HR) Generalist, on 12/03/24 at 12:58 PM, they conducted twice a month. Please
stated, “I don’t see one in their first 90 days.” see attached Policy.
0715 Personnel-Agency record requirements Based on interview and personnel record review, the 0620 Management of human
WAC 246-341-0510(1)(d)(i) A behavioral agency failed to ensure all staff had ongoing training resources
health agency must maintain a personnel in the personnel record. WAC 246-337-050(5)(a)
record for each person employed by the Deficiency has been corrected as
agency. (1) The personnel record must contain Failure to ensure ongoing training may result in client followed:
all of the following: (d) A record of annual harm. Cultural Competency Trainings
training that includes: (i) Cultural competency. have been identified in staff files
Findings included: and titled “Implicit Bias.”
Transcripts for Staff B have been
1. Review of the personnel record for Staff B, attached for confirmation of
Administrative Assistant, showed that there were no cultural competency training in
annual cultural competency trainings in their personnel file. Human Resources
personnel file. has been educated on training
2. During an interview with Staff E, HR Generalist, on module titles and their contents.
12/03/24 at 11:45 AM, they stated, “I don’t see any In July 2024, the organization
cultural competency trainings in the file.” switched to Relias Training
Program and implemented an
Education Fair in which all
required annual trainings are
automatically assigned to all
staff.
0925 Individual service record content Based on clinical record review and interview, the 0925 Individual service record
WAC 246-341-0640(1)(a) A behavioral health agency failed to provide documentation that content
agency is responsible for the components and individuals received a copy of counselor disclosure WAC 246-341-0640(1)(a)
documentation in an individual's individual requirements as required for the counselor credential Deficiency will be corrected as
service record content unless specified for 4 of 4 clinical records reviewed (Client #1-#4). followed: Discharge Letters are
otherwise in certification or individual service signed and provided to each
requirements. (1) The individual service record Failure to ensure all clients receive the counselor client upon discharge. We have
must include: (a) Documentation the disclosure requirements and show documentation in submitted a request to our EHR to
individual received a copy of counselor the clinical record may result in clients not choosing add in a field for treatment team
disclosure requirements as required for the counselors who best suit their needs and can result names and credentials on this
counselor's credential. in poor client outcomes. letter.
Findings included:
1. Review of the clinical record for Client #1, Client
#2, Client #3, and Client #4 showed they did not
contain a counselor disclosure as required for the
counselor’s credential.
2. During an interview with Staff E, Administrator, on
12/03/24 at 2:28 PM, they stated, “We have it on the
wall, just not a detailed copy for the clients.”
Introduction
We require that you submit a plan of correction for each deficiency listed on the inspection report form. Your plan of correction must be
submitted to the DOH within ten business days of receipt of the list of deficiencies.
Descriptive Content
Your plan of correction must provide a step-by-step description of the methods to correct each deficient practice to prevent recurrence and
provide information that ensures the intent of the regulation is met.
An acceptable plan of correction must contain the following elements:
• The plan of correcting the specific deficiency;
• The procedure for implementing the acceptable plan of correction for the specific deficiency cited;
• The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected
and/or in compliance with the regulatory requirements;
• The title of the person responsible for implementing the acceptable plan of correction.
Simply stating that a deficiency has been "corrected" is not acceptable. If a deficiency has already been corrected, the plan of correction
must include the following:
• How the deficiency was corrected,
• The completion date (date the correction was accomplished),
• How the plan of correction will prevent possible recurrence of the deficiency.
Completion Dates
The POC must include a completion date that is realistic and coinciding with the amount of time your facility will need to correct the
deficiency. Direct care issues must be corrected immediately and monitored appropriately. Some deficiencies may require a staged plan to
accomplish total correction. Deficiencies that require bids, remodeling, replacement of equipment, etc., may need more time to
accomplish correction; the target completion date, however, should be within a reasonable and mutually agreeable time-frame.
Continued Monitoring
Each plan of correction must indicate the appropriate person, either by position or title, who will be responsible for monitoring the
correction of the deficiency to prevent recurrence.
Checklist:
• Before submitting your plan of correction, please use the checklist below to prevent delays.
• Have you provided a plan of correction for each deficiency listed?
• Does each plan of correction show a completion date of when the deficiency will be corrected?
• Is each plan descriptive as to how the correction will be accomplished?
• Have you indicated what staff position will monitor the correction of each deficiency?
• If you included any attachments, have they been identified with the corresponding deficiency number or identified with the page
number to which they are associated?
Your plan of correction will be returned to you for proper completion if not filled out according to these guidelines.
Note: Failure to submit an acceptable plan of correction may result in enforcement action.
Approval of POC
Your submitted POC will be reviewed for adequacy by DOH. If your POC does not adequately address the deficiencies in your inspection
report you will be sent a letter detailing why your POC was not accepted.
Questions?
Please review the cited regulation first. If you need clarification, or have questions about deficiencies you must contact the inspector who
conducted the onsite inspection, or you may contact the supervisor.
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
2/18/2025
Newport Academy - Seattle
12029 113th Ave NE
Kirkland, WA 98034-6901
Re: Exam Number: X2024-958
License Number: BHA.FS.61015899
Approved Plan of Correction
Date(s) of Inspection: 12/03/24
Dear Administrator:
This letter is to inform you that after careful review of the Plan of Correction (POC) you
submitted for the exam recently conducted at your facility, the Department has determined that
the POC is approved.
Based on the scope and severity of the deficiencies listed in your statement of deficiency report,
the Department will not conduct an announced follow-up compliance visit to verify that all
deficiencies have been corrected.
Reviewer: ECR03
Department of Health
HSQA/Office of Health Systems Oversight
PO Box 47874
Olympia, Washington 98504-7874

administrator: David Laxton


facility_name: Pearl Youth Residence

summary: State Inspection

raw_content:
Behavioral Health Agency Inspection Report
Department of Health
P.O. Box 47874, Olympia, WA 98504-7874
TEL: 360-236-4732
March 31, 2021
Pearl Youth Residence, 1201 S Proctor St, Tacoma, WA. 98405-2047 April Stallings
Agency Name and Address Administrator
ONGOING - ROUTINE 03/23/2021 Jewelya M Ianniciello SUDP LICSW
CIYT CCTP MAC
Inspection Type Inspection Onsite Dates Inspector
X2021-199 BHA.FS.61067737
Inspection Number License Number
Please note that the deficiencies/violations/observations noted in this report are not all-inclusive, but rather were deficiencies/violations/observations that were
observed or discovered during the on-site inspection.
Deficiency Number and Rule Reference Observation Findings Plan of Correction
0650 Administrator key responsibilities Based on the agency’s policies and procedures and record Pearl Youth Residence (PYR)
WAC 246-341-0410(2)(b) (2) The administrator review, the agency failed to adhere to ensuring all programs Program Director and Medical
must:(b) Ensure administrative, personnel, and across the organization and sites were consistent in clinical Services Manager will remind the Commented [IJM(1]: I am unclear of the point to the
clinical policies and procedures are adhered to and documentation and processes. clinical/medical team to document “reminders” as part of the plan of correction?
kept current to be in compliance with the rules in this sources of information in client
chapter, as applicable; Failure to ensure systematic formatting that meets all record and/or where the referral
Washington Administrative Codes (WAC) required elements information can be found by
has led to WAC deficiencies, inconsistent processes among 4/23/21.
programs, clinical documentation that displayed staff’s
inability to practice within the rules of WAC 246-341 and may QI and PYR's Program Analyst and
lead to compromised treatment outcomes. Health Information Technician will
review 15 randomly selected
Findings include: forms/documents in 10 PYR charts
1. The agency policies and procedures indicate the for the dates of 4/24/21 - 6/30/21
agency will adhere and meet all the WAC by 7/31/21 and report observations
requirements and encompass all the required WAC to the PYR Program Director.
elements within clinical documentation.
• Staff are trained and sign off that they understand all
WAC requirements under the 246-341 chapter.
2. Clinical chart review confirmed inconsistent
formatting as it pertained to WAC required elements
across programs and sites.
• The agency organization has three different
electronic platforms that do not interact and have
different documentation formats: MyAvatar,
Extended Reach and Med Order. Documentation
within progress notes for transition of care from one
program to another was sporadic and difficult at
times to follow the clinical narrative of care. Some
progress notes are titled “Crisis Intervention Note”
for billing purposes not connected to the service
provided.
1540 Clinical Add record content Based on the agency’s policies and procedures, record review Pearl Youth Residence (PYR)
WAC 246-341-0640(17) Each agency licensed by the and interview, the agency failed to ensure clinical progress Program Director and Medical
department to provide any behavioral health service notes meet all the WAC required elements. Services Manager will remind the Commented [IJM(2]: The concern was about inconsistent
is responsible for an individual's clinical record clinical/medical team to document formatting
content. The clinical record must include:(17) Failure to ensure the clinical progress notes meet all the WAC sources of information in client
Progress notes must include the date, time, duration, required elements may lead to misrepresentation of the record and/or where the referral
participant's name, response to interventions, and a clinical narrative, unmet treatment needs and inability to information can be found by
brief summary of the session and the name and identify clinical staff practicing within their scope. 4/23/21.
credential of the staff member who provided it;
Findings include: QI and PYR's Program Analyst and
1. The agency policies and procedures indicate the Health Information Technician will
clinical charts will address, reflect and document all review 15 randomly selected
the WAC requirements. forms/documents in 10 PYR charts
2. Based on the review of the clinical progress notes, for the dates of 4/24/21 - 6/30/21
there was inconsistent formatting between programs by 7/31/21 and report observations
that were lacked time, duration and the credentials to the PYR Program Director.
of the staff member providing the service. The
current EHR format captures the staff member’s
education level, sporadic capture of DOH credential.
3. During an interview on 3/23/2021 at, 10:00 AM, Staff
A – Quality Improvement acknowledged the different
formatting between programs and the missing WAC
elements. A clinical service time report was produced
to verify the internal QI process.
1820 OS Psychiatric and medication support Based on the agency’s policies and procedures and record At the May 2021 monthly provider
WAC 246-341-0712(1)(d) Psychiatric medication review, the agency failed to ensure clinical documentation meeting, the Chief Medical Officer,
mental health services are a variety of activities was consistent in how the prescriber informs of the potential Dr. Davydow, will review this
related to prescribing and administering medication, benefits and side effects of the prescribed medications as finding with CLR medical staff and
including monitoring an individual for side effects and noted in the agency’s P&Ps.
will educate providers that when a
changes as needed. These services may only be
medication is prescribed, they must
provided with one of the outpatient mental health Failure to follow the procedure in the agency’s P&P as it
document the indication of the
services in WAC 246-341-0700 (1)(a) through (e). An pertains to how the clinical documentation will demonstrate
medication for that client in the
agency providing psychiatric medication services may how the individual has been informed of the benefits and
also provide medication support services, described side effects of the prescribed medication may lead to the clinical note for that encounter.
in subsections (2) and (3) of this section.(1) An agency misrepresentation that the individual has not been informed, The Chief Medical Officer and QI
providing psychiatric medication services must:(d) lacked on consistent procedure, individuals not staff will randomly audit clinical
Have a process by which the medication prescriber understanding the purpose of the prescribed medications and charts of each provider to ensure
informs either the individual, the legally responsible potential public safety concerns. compliance with documentation of
party, or both, and, as appropriate, family members, clinical indications for prescribed
of the potential benefits and side effects of the Findings include: medications.
prescribed medication(s); 1. The agency policies and procedures indicate the
Providers who are not documenting
clinical charts will indicate the individual has been
the information will receive
informed by documentation in the prescriber’s
reminders with the goal of 100%
clinical note, a separate medication benefit and side
documentation by September 2021
effect form and/or notated in the prescription orders.
2. During the clinical chart review, documentation was
inconsistent. Documentation of the purpose for the The Chief Medical Officer will also
medication was sporadic. communicate the need for similar
• When not identifying the purpose of a medication documentation from any non-CLR
that could be used for different reasons, it can lead to clinical providers working with CLR
confusion for the consumer, staff and disempower clients (e.g., the Multicare Mobile
the consumer in self-advocacy of their care that may Primary Care Bus).
lead to compromised treatment outcomes.
3. During an interview on 3/23/2021 at, 10:15 AM, Staff
QI Staff will conduct a random
A – Quality Improvement acknowledged the
survey of 25 charts receiving
inconsistency in documentation.
medication services in CLR,
including all sites. Reviews will be
on all forms in each
chart (assessments, treatment
plans, discharge summaries,
medication progress notes...) to
determine if the purpose of
medication is being pulled into all
forms and/or reports.
This information will be shared with
Dr. Davydow and if necessary the IT
Director or any other managers
necessary to determine if the
Avatar or Extended Reach reports
need to be updated or any other
next steps.
Introduction
We require that you submit a plan of correction for each deficiency listed on the inspection report form. Your plan of correction must be
submitted to the DOH within ten business days of receipt of the list of deficiencies.
Descriptive Content
Your plan of correction must provide a step-by-step description of the methods to correct each deficient practice to prevent recurrence and
provide information that ensures the intent of the regulation is met.
An acceptable plan of correction must contain the following elements:
• The plan of correcting the specific deficiency;
• The procedure for implementing the acceptable plan of correction for the specific deficiency cited;
• The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and/or in
compliance with the regulatory requirements;
• The title of the person responsible for implementing the acceptable plan of correction.
Simply stating that a deficiency has been "corrected" is not acceptable. If a deficiency has already been corrected, the plan of correction must
include the following:
• How the deficiency was corrected,
• The completion date (date the correction was accomplished),
• How the plan of correction will prevent possible recurrence of the deficiency.
Completion Dates
The POC must include a completion date that is realistic and coinciding with the amount of time your facility will need to correct the deficiency.
Direct care issues must be corrected immediately and monitored appropriately. Some deficiencies may require a staged plan to accomplish total
correction. Deficiencies that require bids, remodeling, replacement of equipment, etc., may need more time to accomplish correction; the target
completion date, however, should be within a reasonable and mutually agreeable time-frame.
Continued Monitoring
Each plan of correction must indicate the appropriate person, either by position or title, who will be responsible for monitoring the correction of
the deficiency to prevent recurrence.
Checklist:
• Before submitting your plan of correction, please use the checklist below to prevent delays.
• Have you provided a plan of correction for each deficiency listed?
• Does each plan of correction show a completion date of when the deficiency will be corrected?
• Is each plan descriptive as to how the correction will be accomplished?
• Have you indicated what staff position will monitor the correction of each deficiency?
• If you included any attachments, have they been identified with the corresponding deficiency number or identified with the page number to
which they are associated?
Your plan of correction will be returned to you for proper completion if not filled out according to these guidelines.
Note: Failure to submit an acceptable plan of correction may result in enforcement action.
Approval of POC
Your submitted POC will be reviewed for adequacy by DOH. If your POC does not adequately address the deficiencies in your inspection report you
will be sent a letter detailing why your POC was not accepted.
Questions? Please review the cited regulation first. If you need clarification, or have questions about deficiencies you must contact the inspector
who conducted the onsite inspection, or you may contact the supervisor.
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
April 28, 2021
RE: Inspection Number - x2021-199 License Number - BHA.FS.61067737
Pearl Youth Residence
1201 S Proctor St
Tacoma, WA. 98405-2047
Dear Ms. April Stallings,
The Washington State Department of Health conducted a Behavioral Health Review
of Pearl Youth Residence, 1201 S Proctor St, Tacoma, WA. 98405-2047 on
3/23/2021.
The Plan of Correction that was submitted on 04/23/2021 along with the POC
clarification email on 4/28/2021 has been approved on 04/28/2021 with no further
action required.
I sincerely appreciate your cooperation and hard work during the review process and
look forward to working with you again in the future. Please contact me if there are
questions regarding the review process. I may be reached at (360) 480-5666. I am
also available by email at Jewelya.Ianniciello@doh.wa.gov
Sincerely,
Jewelya M Ianniciello SUDP LICSW CIYT CCTP MAC
Behavioral Health Reviewer
Office of Health Systems Oversight

administrator: April Stallings


summary: State Investigation

raw_content:
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
March 11, 2022
Pearl Youth Residence
1201 S Proctor St
Tacoma, WA 98405-2047
Re: Complaint Investigation
Case Number: 2021-10597 RTF, 2021-10598 BHA
License Number: RTF.FS.61067805, BHA.FS.61067737
Dear Mr. Aldridge:
The State of Washington Department of Health recently completed an investigation of Pearl
Youth Residence on March 2, 2022.
No deficiencies will be cited as a result of this investigation.
Please retain a copy of this letter for your files.
Thank you for your time and assistance during this investigation.
Investigator: 33894
Department of Health
HSQA/Office of Health Systems Oversight
PO Box 47874
Olympia, Washington 98504-7874


report_date: February 16,2021

summary: State Investigation

raw_content:
STATE 01' WASHINGTON
DEPARTMENT OF HEALTH
February 16,2021
Pearl Youth Residence
1201 S Proctor St.
Tacoma, WA 98405-2047
Re: Complaint Investigation
Case Number: 2020-17031
License Number: BHA.FS.61067737
Dear Mr. Aldridge:
The State of Washington Department of Health recently completed an investigation of Pearl
Youth Residence on January 27, 2021.
No deficiencies will be cited as a result of this investigation.
Please retain a copy of this letter for your files.
Thank you for your time and assistance during this investigation.
Investigator: 33894
Department of Health
HSQA/Office of Health Systems Oversight
PO Box 47874
Olympia, Washington 98504-7874


summary: State Investigation

raw_content:
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
February 16,2021
Pearl Youth Residence
5201 S Proctor St
Tacoma, WA 98405-2047
Re: Complaint Investigation
Case Number: 2020-16052 RTF, 2020-16053 BHA
License Number: BHA.FS.61067737, RTF.FS.61067805
Dear Mr. Aldridge:
The State of Washington Department of Health recently completed an investigation of Pearl
Youth Residence on January 27, 2021.
No deficiencies will be cited as a result of this investigation.
Please retain a copy of this letter for your files.
Thank you for your time and assistance during this investigation.
Investigator: 33894
Department of Health
HSQA/Office of Health Systems Oversight
PO Box 47874
Olympia, Washington 98504-7874


report_date: February 16, 2021

summary: State Investigation

raw_content:
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
February 16, 2021
Pearl Youth Residence
1201 S Proctor St.
Tacoma, WA 98405-2047
Re: Complaint Investigation
Case Number: 2020-15971 BHA, 2020-15972 RTF
License Number: BHA.FS.61067737, RTF.FS.61067805
Dear Mr. Aldridge:
The State of Washington Department of Health recently completed an investigation of Pearl
Youth Residence on January 20, 2021.
No deficiencies will be cited as a result of this investigation.
Please retain a copy of this letter for your files.
Thank you for your time and assistance during this investigation.
Investigator: 33894
Department of Health
HSQA/Office of Health Systems Oversight
PO Box 47874
Olympia, Washington 98504-7874


summary: State Investigation

raw_content:
STATI; 01-' WASiiINGTON
DEPARTMENT OF HEALTH
March 22, 2021
Comprehensive Life Resources - Pearl Youth Residence
121 South Proctor Street
Tacoma, WA 98405-2047
Re: Complaint Investigation
Case Number: 2020-15173
License Number: BHA.FS.61067737
Dear Melissa Olson:
The State of Washington Department of Health recently completed an investigation of
Comprehensive Life Resources - Pearl Youth Residence on March 18, 2021.
No deficiencies will be cited as a result of this investigation.
Please retain a copy of this letter for your files.
Thank you for your time and assistance during this investigation.
Investigator: JAMC03
Department of Health
HSQA/Office of Health Systems Oversight
PO Box 47874
Olympia, Washington 98504-7874


summary: State Investigation

raw_content:
STATKOl-'WASiiINGTUN
DEPARTMENT OF HEALTH
March 22,2021
Comprehensive Life Resources - Pear! Youth Residence
121 South Proctor Street
Tacoma,WA 98405-2047
Re: Complaint Investigation
Case Number: 2020-13707 BHA
License Number: BHA.FS.61067737
DearMelissa Olson;
The State of Washington Department of Health recently completed an investigation of
Comprehensive Life Resources - Pearl Youth Residence on March 22, 2021.
No deficiencies will be cited as a result of this investigation.
Please retain a copy of this letter for your files.
Thank you for your time and assistance during this investigation.
Investigator: JAMC03
Department of Health
HSQA/Office of Health Systems Oversight
PO Box 47874
Olympia, Washington 98504-7874


summary: State Investigation

raw_content:
STATI; 01-' WASHINGTON
DEPARTMENT OF HEALTH
May 12,2021
Comprehensive Life Resources - Pearl Youth Residence
121 South Proctor Street
Tacoma, WA 98405-2047
Re: Complaint investigation
Case Number: 2020-13517
License Number: BHA.FS.61067737
Dear MeHssa Olson:
The State of Washington Department of Health recently completed an investigation of
Comprehensive Life Resources ~ Pearl Youth Residence on April 2, 2021.
No deficiencies will be cited as a result of this investigation.
Please retain a copy of this letter for your files.
Thank you for your time and assistance during this investigation.
Investigator: JAMC03
Department of Health
HSQA/Offlce of Health Systems Oversight
PO Box 47874
Olympia, Washington 98504-7874


summary: State Investigation


summary: State Investigation

deficiencies: WAC 246-341-0365 and WAC 246-337-990 In addition, the Department reserves the right to pursue enforcement action for any repeat and/or uncon'ected deficiencies based on applicable statute and rules. Please feel free to contact me at the email address you have on file if you have questions regarding the investigation. I appreciate your cooperation and time during the investigation. Investigator 42124


facility_name: Daybreak Youth Services – Brush Prairie

report_id: M2024-435 Summary Action Order

summary: Enforcement

report_category: enforcement

inspection_number: M2024-435 Summary Action Order


report_id: M2024-435 Notice of Intent

summary: Enforcement

inspection_number: M2024-435 Notice of Intent


report_id: M2022-553 Summary Action Order

summary: Enforcement

inspection_number: M2022-553 Summary Action Order


report_id: M2022-553 Notice of Intent

report_date: January 1, 2005

summary: Enforcement

raw_content:
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
SECRETARY OF HEALTH
In the Matter of No. M2022-553
DAYBREAK YOUTH SERVICES " SPOKANE NOTICE OF INTENT TO
License Nos. RTF.FS.00001010 SUSPEND
Respondent
Pursuant to RCW 43.70,115, the Executive Director of the Department of Health
(Department), Residential Treatment Faciiities Program (Program), on designation by the
Secretary, having authority to regulate Residentia! Treatment Facilities (RTFs) under
chapters 71.12 RCW and 246-337 WAC, hereby provides Notice of Intent to Suspend
License No. RTF.FS.00001010, This Notice wii! take effect and become a FEna! Order,
without further notice, twenty-eight (28) days after receipt, absent a timely request for an
adjudicative proceeding. This Notice is based on the foliowing findings of fact and
conclusions of law,
1. FINDINGS OF FACT
1.1 The Program is a sub-unitofthe Department with authority to Eicense and
regulate RTFs. The Program's authority to license and regulate RTFs is found at
RCW 71.12 and WAG 246-337, and inciudes authority to review all records and
interview all RTF clients and RTF staff. RCWs 71.12.500 through ,530.
1,2 On January 1, 2005, the State of Washington issued Daybreak Youth
Services - Spokane, located at 628 S. Cowiey Street, Spokane, WA 99202
(Daybreak-Spokane), license no. RTF.FS.00001010 to operate as an RTF.
Daybreak-Spokane's RTF license is currently active.
1.3 Daybreak-Spokane is a non-profit RTF providing co-occumng disorder
treatment services to youth. In addition to being required to compiywith state licensing
laws, Daybreak must also comply with 42 USC § 290dd-2 and 42 CFR part 2 (Part 2),
1,4 Part 2 is a federai law that protects the confidentiality of substance use
disorder (SUD) records and information in the possession of Part 2 covered programs,
such as Daybreak-Spokane, and in the possession of other lawful holders. In general,
NOTICE OF INTENT TO SUSPEND PAGE 1 OF 11
NO. M2022-553
Part 2 prohibits Part 2 covered programs from disclosing Part 2 covered records and
information without patient consent. However, Part 2 permits Part 2 covered programs
to disclose Part 2 covered records and information to state agencies "authorized by law
to regulate the activities of the Part 2 program." 42 CFR § 2.53 (b)(2)(i). The Program is
authorized by law to regulate the activities of Daybreak-Spokane. Daybreak-Spokane is
therefore permitted to allow the Program to review, copy, remove, download, or forward
patient records so long as the Program agrees in writing to comply with the conditions
outlined in 42 CFR § 2.53(b)(1).
1.5 On or about February 10, 2022, the Program assigned an investigation of
Daybreak-Spokane to Program investigator Deborah (Deb) Duke (Investigator Duke).
The investigation (case no, 2022-1206) was based on a report from Department of
Children, Youth and Families Child Protective Services (DCYF/CPS) regarding
concerns of serious staff-to-client boundary violations by a staff person at
Daybreak-Spokane, Staff Member A. In March 2022 the Program received a second
complaint from the Spokane Police Department regarding the same staff-to-patient
boundary violations, and a second investigation (case no. 2022-4047) was
subsequently assigned to Investigator Duke in response to it. As part of its
investigations, the Program informed Daybreak-Spokane in writing that the Program
would comply with the conditions in 42 CFR § 2,53(b)(1) to protect Part 2 covered
records and information obtained from Daybreak.
1.6 Staff Member A was hired by Daybreak-Spokane as a skills coach in
November 2021. Staff Member A's duties included daily contact with minor female
patients at Daybreak-Spokane.
1.7 During employment at Daybreak-Spokane, Staff Member A ailegedly
engaged in inappropriate contact and boundary vioiations with minor female clients. The
conduct started on or around Staff Member A's start date with Daybreak-Spokane, and
included, but was not limited to:
A. A visit to Daybreak-Spokane on or about December 8, 2021, to
"hang with the giris," i.e., minor clients at Daybreak-Spokane, on Staff
Member A's day off. This visit resulted in counseling by Daybreak-Spokane.
// . - . •
NOTICE OF INTENT TO SUSPEND PAGE 2 OF 11
NO. M2022-553
B. A grievance filed by Client A on December 29, 2021 with
Daybreak-Spokane detailing Staff Member A hugging Client A and using
"prison sign language" to say he loved her.
C. A report on or about January 19,2022 that Staff Member A
engaged with Client B via Staff Member A's personal social media
account
D. Asking clients for hugs and talking to them about their bodies.
When rebuffed by a client who did not want to be hugged, Staff Member A
became confrontational.
E. Sharing iunch trays with clients.
F. Telling clients that grievances had been filed against him by clients.
G. Teiiing a client that an implant En her arm was "disgusting."
H. "Slut-shaming" clients by commenting about their clothing choices.
1.8 In response to clients' grievances regarding Staff Member A's alleged
misconduct, Staff Member A ai!eged!y engaged in retaliation and bullying against minor
female clients.
1.9 Following reports of Staff Member A's alleged behavior and concerns with
the quality of care and/or management and oversight at Daybreak-Spokane, the Idaho
Department of Health and Welfare suspended all referrals to Daybreak.
1.10 On information and belief, on or about January 19, 2022, Daybreak-
Spokane initiated an internal investigation regarding Staff Member A's alleged
misconduct. Though this internal investigation showed a concerning pattern of
misconduct, the conclusion of the investigation was that Staff Member A had not
violated Daybreak-Spokane's code of ethics. Staff Member A remained employed by
Daybreak-Spokane and had continued access to minor clients.
1.11 Daybreak did not report any of the above complaints or concerns, or
subsequent complaints and concerns, regarding Staff Member A to the Program.
1,12 The Program conducted its first on-site investigative visit to
Daybreak-Spokane on or about March 8-9, 2022. Daybreak-Spokane was cooperative
during this visit and provided the Program access to Staff Member A's training records
and improvement plan. The Program conducted a second on-site investigative visit to
Daybreak-Spokane on or about April 11-12, 2022, during which the Program
NOTICE OF !NTENT TO SUSPEND PAGE 3 OF 11
NO. M2022-553
interviewed Staff Member A. Daybreak-Spokane was cooperative during this
investigative visit, as well.
1.13 On or about May 9, 2022, the Program met virtual!y with members of
Daybreak's management team to discuss the next steps in the Program's
investigations. During this meeting, the Program requested access to, or copies of, the
complete dient records for specified clients; access to aii grievances filed against Staff
Member A; all supervision notes related to Staff Member A; and assistance with
scheduling additional Daybreak-Spokane staff interviews. At this meeting, Investigator
Duke probed Daybreak-Spokane on why client and staff complaints about Staff
Member A were not reported to the Program.
1,14 Between May 9 and May 24, 2022, Daybreak-Spokane did not provide the
Program with the information the Program requested during the May 9, 2022 meeting.
Additionally, Daybreak-Spokane did not facililate staff interviews or client interviews. As
a result of Daybreak-Spokane's non-responsiveness to the Program's investigative
requests, on or about May 24-25, 2022, Program investigators went on-site to
Daybreak-Spokane to continue to investigate Daybreak-Spokane's responses to the
alleged misconduct by Staff Member A and any related, alleged staff misconduct.
1,15 During prior investigations predating the Program's investigations arising
out of the allegations about Staff Member A, Daybreak-Spokane had provided Program
investigators with access to, or copies of, complete client records. During the
May 24-25, 2022 investigative visit, Daybreak-Spokane allowed the Program to review
parts of three clients' records, but Daybreak refused Program investigators access to
the complete client records. Program also requested copies ofai! grievances or
complaints regarding Staff Member A, and received only one In response to this
request. Program investigators left the facility due to a lack of cooperation by
Daybreak-Spokane, which prevented access to evidence requested in the investigation.
1.16 On or about May 26, May 27, June 2, and June 22, 2022, Daybreak-Spokane,
through counsel, stated that it intended to cooperate with the Program's investigation.
However, the stated intent to cooperate came with caveats. The communications indicated
that Daybreak-Spokane questioned the scope of the Program's investigation and how the
Program's request for access to records and information was compatible with Part 2.
.NOTICE OF INTENT TO SUSPEND PAGE 4 OF 11
NO. M2022-553
1.17 The Program directly addressed Daybreak-Spokane's questions regarding
the Program's investigations. On July 7, 2022, the Program sent Thomas (Tom) Russell,
Daybreak CEO, an investigative request letter, outlining the purpose of the Program's.
investigation; the scope of the Program's investigation; the information to which the
Program required access in order to conduct its investigation; and the Program's legal
authority to conduct the investigation. In this letter, the Program, In writing, again
reiterated its commitment to abide by Part 2, specifically listing the conditions identified
at 42 CFR§ 2.53(b)(1). The letter informed Daybreakfhe Program would be re-initiating
its investigation on July 13, 2022.
1.18 On July 13, 2022, investigator Duke emailed DaybreakCEO Mr. Russell
and Daybreak empioyee Sandra Skok, notifying them the Program was continuing the
investigation of cases regarding al!egations of inappropriate staff behaviors at
Daybreak-Spokane. Investigator Duke requested the foiiowing information, which was
needed to move the investigation forward:
e Copies of aii complaints and grievances regarding any aliegations of
inappropriate staff behaviors, including any behaviors that made clients
feel uncomfortable, from July 1 , 2021 to the present,
< A staff list with Job titles and scheduling information, such as shifts and
days each person works. Ms. Duke noted the Program intended to be
on-site for staff interviews.
* The entire client records for five, specificaily identified clients.
1.19 On July 14, 2022, Daybreak, through counsel, responded to the Program's
July 13, 2622 email. Daybreak agreed to provide the Program's investigators access to
280 pages of documents and access to a "smail number of employees necessary for
DOH to conduct the review" described in the Department's Juiy 7, 2022 letter. However,
Daybreak objected to parts of Investigator Duke's investigative request, arguing it was
overly broad. Moreover, Daybreak dedined to provide Investigator Duke ali of the client
records requested, arguing the request was inconsistent with Part 2.
1.20 On July 18, 2022, Program investigators arrived at Daybreak-Spokane to
continue their investigation on-site. The Program's on-site investigation plan was to
obtain and/or review client records, interview staff, and interview clients receiving
NOTICE OF INTENT TO SUSPEND PAGE 5 OF .11
NO. M2022-553
services at Daybreak-Spokane on July 18 and 19. The Program's investigative plan was
within the scope of its investigative authority and did not conflict with Part 2.
1.21 On July 18, 2022, the Program met with Daybreak-Spokane to attempt to
obtain the information and records it needed. The same day, Daybreak CEO Mr. Russell
emailed investigator Duke to document a conversation they had regarding the
investigation. The email indicated the Program and Daybreak agreed about the scope of
the investigation, and Daybreak would provide the Program with the client records the
Program requested and would arrange staff interviews. However, Mr. RusseiE stated the
Department could not interview clients without receiving their written consent, and
suggested the Program's and Daybreak's attorneys discuss the contents of a written
consent.
1.22 On Ju!y 18, 2022, the Program interviewed Director of Nursing Becky Pulito,
Mental Health Therapist Samantha Brown, and Admissions Manager Amanda Kerr.
Daybreak CFO Richard Reathaford and Daybreak Talent Acquisition Specialist Sachelie
McKenna attended the interviews. During the interviews, Mr. Reathaford interjected,
attempted to control the scope of the questioning, answered for an Enterviewee, and
would not a!low interviewees to respond to questions he believed were, in his words,
"he-said, she-said" questions. Moreover, the Program did not receive any of the client
records it requested and were not allowed to interview clients, purportedly because of
Part 2 restrictions.
1.23 On July 1 9, 2022, Program investigators arrived at Daybreak-Spokane at
6:15 AM. The Program's plan for the day was to conduct staff interviews, interview
dients, and review or obtain client records. The Program's July 19 investigation
unfolded as follows:
1.23.1 The Program first attempted to interview Team Leader
Nyneave Beach, with Mr. Reathaford and Ms. McKenna present. Shortly after the
Program began its interview, Mr. Reathaford interrupted, directing Nyneave Beach
to oniy answer questions related to policies, procedures, and processes.
Ms. Beach appeared confused, and stated that she couldn't answer the questions
without using "he-said, she said" information. Ms. Beach proceeded to answer
questions about select Daybreak processes and the interview conduded, but
NOTICE OF INTENT TO SUSPEND PAGE 6 OF 11
NO. M2022-553
Ms. Beach was unable to answer ail of the Program's questions due to
Mr. Reathaford's interference.
1.23.2 The next Daybreak staff member the Program interviewed
was Skills Coach Jessica Rose. Mr. Reathaford and Ms. McKenna were present.
Mr. Reathaford again interrupted the Program's interview, arguing the scope of
the interview was limited to discussing policies and procedures oniy, which
tmncated the interview.
1.23.3 The Program next attempted to jnten/iew Skills Coach
Joseph Aviia. Mr. Reathaford and Ms. McKenn'a were present. The Program
asked Mr. Avila a question about staff-to-patient interactions that could make a
client feei uncomfortable. At this question, Mr. Reathaford interrupted and
became confrontational with the Program. Mr. Reathaford argued that Mr. Avila
could not answer the question because it called for specuiation, asking how
would Daybreak staff know what made a client uncomfortable. Mr. Reathaford
also argued the questions were outside the scope of the investigation.
Mr. Reathaford instructed Mr. Avila to answer questions only about policies and
procedures, again making a thorough interview impossible.
1,23.4 The next Daybreak staff member the Program attempted to
interview was Substance Use Disorder Professional Danica Skalski. Mr. Reathaford
and Ms, McKenna were present. Mr. Reathaford interrupted the interview, and
directed Ms. Skaiski to answer questions about policies and procedures only.
1.23.5 After the interview with Ms. Skalski, Investigator Duke spoke
to Mr. Reathaford about his conduct during the interviews, investigator Duke
informed Mr. Reathaford that his ongoing interference with and interruption of
interviews was inappropriate, and that staff must be allowed to answer the
questions asked without his interference. Mr. Reathaford stated it was his role to
ensure the Program stayed within what Daybreak perceived to be the proper
parameters of the investigation. Mr. Reathaford told Investigator Duke she was
being misleading to Daybreak staff, and she made them feel uncomfortable.
1.23.6 At about 1 1:00 AM, the Program's investigative manager
emailed Mr. Reathaford and instructed him to stop interfering with the Program's
interviews.
NOTICE OF INTENT TO SUSPEND PAGE 7 OF 11
NO. M2022-553
1.23.7 Investigator Duke and Mr. Reathaford spoke again about
Mr. Reathaford's conduct during the inten/Eews. Investigator Duke asked him to
refrain from interrupting and interfering with interviews. Mr. Reathaford
responded that he was doing what he was there to do, which was to prevent the
Program from exceeding Daybreak's perceived scope of the investigation.
Mr. Reathaford stated he was directed to do this by Daybreak's attorney,
David Smith, investigator Duke asked Mr. Reathaford, "...to be clear, you're
telling me that if you don't agree with the way things are said, you're going to say
something?" Mr. Reathaford responded he would interrupt and that it was his role
and obligation to do so. Mr, Reathaford stated, "i wiii not allow questions to
deviate from policy and procedure," and for that reason he "politely re-directed
staff when they were attempting to answer questions" and would continue to do
so.
1.23.8 Mr, Reathaford's disruptive conduct and his promise to
continue to disrupt the interviews obstructed and would continue to obstruct the
flow of information. Such obstmctive conduct compromised the reliability of the
staff Enten/iews. For these reasons, the Program determined that continuing staff
interviews would not be fruitful.
1,23.9 The Program again requested to interview Daybreak-Spokane
clients. Daybreak denied this request, citing Part 2. Daybreak-Spokane's denia! of
access to interview clients prevents the Program from understanding how
Daybreak-Spokane staff behavior impacted client treatment and safety.
1,23.10 Daybreak-Spokane provided the Program 2,450 pages of
hard-copy client records prior to the Program departing the facility on July 19.
However, instead of providing the complete client records as the Program had
requested, Daybreak provided only the records Daybreak deemed to be within
the scope of the Program's investigation.
1.24 Daybreak-Spokane's non-cooperation with the Program's investigations
and obstructive conduct during staff interviews has interfered with the Program's ability
to effectively continue its investigations of Daybreak-Spokane.
//
//
NOTICE OF INTENT TO SUSPEND PAGE 8 OF 11
NO. M2022-553
2. CONCLUSIONS OF LAW
Based on the foregoing Findings of Fact, the Department makes the following
Conclusions of Law:
2.1 The Secretary of Health, acting through his designee, has jurisdiction over
the licensee, Daybreak, and over the subject matter of this proceeding under
chapters 71.12 ROW and 246-337 WAC.
2,2 The Findings of Fact constitute violations of RCW 71 .12.500,
RCW 71.12.510. ROW 71.12.520, WAC 246-337-021 (1)(b), and (2), and
WAG 246-337-095(3).
2,3 The above vioiations demonstrate that Daybreak has failed or refused to
comply with chapters 71.12 RCW and 246-337 WAC.
2.4 Daybreak's failure to comply with chapters 71.12 RCW and 246-337 WAC
provides grounds for the Department to deny, suspend, modify, or revoke Daybreak's RTF
license under chapters 71.12, 43.70, and 34.05 ROW, chapter 246-10 WAG, and
WAC 246-337-021 (6).
2.5' Daybreak has the right to contest a Department decision to deny, modify,
suspend, or revoke its RTF license by requesting an adjudicative proceeding within
twenty-eight (28) days of receipt of the Department's decision. RCW43.70.115, chapter
34.05 ROW, chapter 246-10 WAC, and WAG 246-337-021.
2.6 The Secretary may indicate when and under what circumstances an order
may become an effective Final Order. ROW 43.70.115(2) and ROW 34.05.461.
3. NOTICE OF SUSPENSION
Based on the above Findings of Fact and Conclusions of Law, the Secretary,
through his designee, enters the following:
3.1 License No. RTF.FS.00001010, DAYBREAK YOUTH SERVICES - SPOKANE,
is SUSPENDED INDEFINITELY. The SUSPENSION shall immediately be stayed for 14 days
after this Notice becomes a Final Order.
3.2 Within 7"days after the Notice becomes a FJnai Order, Daybreak shali
submit a closure plan for its RTF, which includes: Information pertaining to the patient
census, case mix, and acuity of clients; explanation of plan to relocate patients to
appropriate care settings that offer similar services, including resources daybreak wili use
NOTICE OF iNTENT TO SUSPEND PAGE 9 OF 11
NO. M2022-553
to support client movement and identification of facilities who have agreed to receive
patients; plan to preserve and transfer client medical records; strategy for notifying clients
and their legal guardians of the license suspension and requirement to transfer patients;
and an explanation of the process for managing pharmacy records and controlled
substances. The closure plan shall be submitted by email to: lan Corbridge, Director,
Office of Community Health Systems, lan.Corbridae(Q)doh.wa.ciov.
3,3 This Notice wil! become a FINAL ORDER without further notice twenty-eight
(28) days from the date of receipt, absent a timely request for an adjudicative proceeding,
4. REQUEST FOR AN ADJUDICATIVE PROCEEDING
If you wish to contest the Department's decision in this matter, you or your
representative must, within twenty-eight (28) days of receipt of this decision, file a
written request with the Department's Adjudicative Service Unit (ASU) in a manner that
shows proof of the service on the ASU. Please use the enclosed form labeled
"Application forAdjudicative Proceeding."
The mailing address is: - The physical address is:
Department of Health Department of Heaith
Adjudicative Service Unit Adjudicative Service Unit
P.O. Box 47879 310 Israel Road SE
Olympia, WA 98504-7879 Tumwater, WA 98501
A copy of the Department's decision must be .attached to the Application for an
Adjudicative Proceeding. FILING SHALL NOT BE DEEMED COMPLETE UNTIL THE
ASU ACTUALLY RECEIVES THE APPLICATION.
//
//
//
//
NOTICE OF INTENT TO SUSPEND PAGE 10 OF 11
NO. M2022-553
You or your representative's FAILURE to submit an Application for an
Adjudicative Proceeding within twenty-eight (28) days of receipt of this decision will
constitute a waiver of the right to a hearing; the Department may decide this matter
without you or your representative's participation and without further notice.
DATED: 8/1 • , 2022.
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
RESIDENTIAL TREATMENT FACILITIES
PROGRAM
'Atf. C^t^-t^
IAN CORBR1DGE
DIRECTOR
OFFICE OF COMMUNITY HEALTH SYSTEMS
RESIDENTIAL TREATMENT FACILITIES
PROGRAM
NOTICE OF INTENT TO SUSPEND PAGE 11 OF 11
NO. M2022-553

inspection_number: M2022-553 Notice of Intent


report_id: M2023-434 Summary Action Order

summary: Enforcement

inspection_number: M2023-434 Summary Action Order


report_id: M2023-434 Notice of Intent

summary: Enforcement

inspection_number: M2023-434 Notice of Intent


report_id: M2022-552 Summary Action Order

summary: Enforcement

inspection_number: M2022-552 Summary Action Order