summary: License Renewals - 32 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care
Licensee: Douglas County Juvenile Department Date of site visit: 4/26/2022 and 4/27/2022
Executive Director: Aric Fromdahl Licensing Coordinator: Mary Torres
Assistant Director: Rob Salerno
Other Regulatory or Accrediting Agencies: Oregon Department of Human Services (ODHS) Child Welfare – Treatment Services, Oregon Health
Authority (OHA), Joint Commission, Oregon Health Authority (OHA)
Program Compliance: The program was found to be compliant or will be compliant with OAR 413-215-0001 to 413-215-0131, Licensing Umbrella
Rules, and OAR 413-215-0501 to 413-215-0586, Licensing Residential Care Agencies Rules. Personnel records were reviewed and compliance
with required background checks was documented for employees in all programs.
Program Description(s): As shared by the program, Foundations, River Rock and Rising Light are Qualified Residential Treatment Programs
(QRTP) as defined under the federal Family First Prevention Services Act. The sites are also approved by ODHS Child Welfare to provide Behavior
Rehabilitation Services (BRS) Residential, Intensive Behavioral Support.The sites were accredited by the Joint Commission in 2020. Foundations
serves all genders ages 12-16, River Rock also serves all genders, but their age range is 13-17. Rising Light serves female youth 12-18 who are
high risk, high acuity and/or victims of the Commercial Sexual Exploitation of Children (CSEC). All facilities provide staff-secure residential services
and/or to provide Individualized Service Plans to youth requiring stabilizations services. The programs provide gender-affirming and inclusive
environment for youth who cannot presently live safely in the community to receive services aimed at developing resiliency, self-direction, and
healthy interdependence in a social setting. Rising Light’s treatment model is Collaborative Problem Solving and their treatment environment
espouses the evidence based My Life, My Choice CSEC Prevention and Recovery Curriculum. Both River Rock and Foundations’ treatment model
is Collaborative Problem Solving and their treatment environment blends elements of the Sanctuary Model and Restorative Justice. We strive to see
the best in each youth who crosses our path and as such, we assume positive intent.
Program type and services: BRS Residential Services - Intensive Behavioral Support – Qualified Residential Treatment Program (QRTP)
Capacity and Age Range:
Foundations Facility: 9 youth, ages 12 – 16
River Rock Facility: 12 youth, ages 13 – 17
Rising Light Facility: 8 youth, ages 12 - 18
(rev. 03/25/2021)
Funding sources: Oregon Department of Human Services (ODHS) Child Welfare Treatment Services, Coos County
Contracts and sources for referrals: Oregon Department of Human Services (ODHS) Child Welfare Treatment Services, Coos County
Average length of stay:
Foundations: 3 – 6 months
River Rock: 3 – 6 months
Rising Light: 4 – 6 months
Average daily population served:
Foundations: 6.60
River Rock: 7.67
Rising Light: 5.30
Number of children served annually:
Foundations: 25
River Rock: 24
Rising Light: 22
Use of seclusion or restraint: The program does not practice seclusion. Staff receive de-escalation and restraint training through Crisis
Prevention Institute (CPI).
Interviews, Observations: Licensing met with the program’s management team at the beginning of the two-day review to include the Assistant
Director, Program Managers and Residential Referral and Admissions Coordinator.
In conversation, the program reports feeling the long-term effects of COVID to include staffing issues. Initial recruitment remains difficult for the
program. Perspective applicants, who generally surface once every 2 months, are only interested in day shifts, Monday through Friday. There is no
interest in swing or graveyard. The program reports having temp on-call positions open for the last 2 years with no interest. Since COVID, the
program has lost 10 to 12 full-time employees, three of those positions being from Foundations. Despite this, the program recently hired two new
employees. A new union contract assisted and provided an increase in pay scale for existing employees. Retention efforts were also bolstered with
money left over from a Child Welfare workforce grant used to alleviate student loan debt for current employees. As a result of the ongoing staffing
issues, the program is considering the permanent closure of Foundations. At the end of December 2021, Foundations’ youth were consolidated into
the River Rock facility. Should Foundations close, the program would be considered fully staffed with its’ existing workforce. The county would
reabsorb the building and could easily repurpose the building. Some ideas include an employee daycare or cafeteria. With the pending closure of
Foundations, the Child Welfare contract will need to be renegotiated on July 1, 2022. Child welfare contracts with Douglas County for 29 beds. The
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current census is 14 youth. The renegotiation of this contract will consequently result in fewer beds. Moving forward, the program would like to
house 13 4o 14 youth at River Rock between the ages of 13 and 17. Rising Light would stay at 8 youth, ages 12 to 18. The day of the tour, River
Rock was going through a remodel. This renovation would add more bedrooms. Currently, the building has 11 bedrooms. There are plans to add
space to increase capacity to 13 or 14 youth, each having their own room.
The following information was shared and gathered over the review process.
- Aside from staffing, the impact of COVID is reflected in the training documentation. Management is confident that training was occurring on
an individual basis, but was not routinely documented. In addition, a reassignment of duties made it difficult to tracking training.
- Management expressed appreciation of the positive experience of the current management team. All three, Program Managers offer strong
leadership and coaching to their staff.
- Recent relations with law enforcement were strained due to the influx of calls related to difficult youth. The relationship is on better terms.
- The program is moving to a new electronic filing system called Blue Step. This filing system will assist with human resources, financial
tracking and has the capability to allow caseworkers to remote in and review their youth's electronic file.
- Rising Light recently hired a second Residential Counselor.
- The program received new vehicles to include three 15-passenger vans, one 14-passenger van, one 7-passenger van, and 2 Impalas. All
staff are trained in the transportation of youth.
A couple of months ago, River Rock lost their on-site therapist. The therapist’s parent agency grew shorthanded and had the therapist return to
their main office. This therapist continues to see Douglas County youth that were already established with her. Youth that arrive to the program
without an established provider are referred to Adapt counseling services. The program makes every effort to maintain youth with their established
mental health providers and will facilitate Zoom and telehealth meetings for continuity of care.
Youth attend school off site. The program’s relationship with Horizon, Horizons, an off-site comprehensive educational setting specifically designed
to meet the needs of traumatized, attachment, and disrupted youth, remains positive. The school recently had two teachers leave, but there still
remains an instructor available for youth. Both River Rock and Rising Light send staff members to be with youth during the school day. River Rock
sends two to three staff members, and Rising Light sends one to two staff members during school hours. Staff transport youth back and forth from
school.
During the review, seven youth, randomly selected from all three programs, were interviewed. All youth report positive interactions with staff on a
one-on-one basis. However, there was some running themes that were brought to light during the interview. Youth report reacting negatively when
staff verbally threatened to write up a “behavioral report,” report back to their POs or take away privileges, as leverage to earn compliance from
youth. Discussion regarding this was held with the management team during the debrief. It was explained by the Program Managers that staff have
been previously discouraged from viewing and utilizing a behavioral report as a punishment. A behavioral report is designed to initiate a “restoration
agreement” between youth and staff. There was conversation about possibly encouraging staff to focus on the restoration aspect and less on the
behavioral report. Several youths also report staff using inappropriate language when addressing youth. Youth were clear that the inappropriate
language is not directed at youth, but rather, used in general speech. It was also reported that staff are inconsistent when it comes to gown and
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mouth searches. Transgender youth share negative experiences within the milieu to include name calling, teasing, and bullying. Youth went on to
say that staff could intervene quicker in these types of situations and have better follow through with the offending. All youth were able to identify a
number of staff who they felt comfortable with talking to should they have any outstanding issue or concern. Strengths identified by the youth
include the number of outings, youth having their own room, and the positive relationships established with their assigned counselors. Other
strengths are that staff “are there” for youth, and that the milieu is more stable now that the younger kids are gone. Areas for improvement or
change identified by youth include staff being more consistent in searches, lessening the “attitude and tone” used by staff, facility cleanliness, the
use of more rugs, comfortable couches, and chairs to make River Rock feel more “homey,” staff refraining from cursing, using the N-word, and not
antagonizing youth. The use of the N-word was described as occurring in the context of a counseling or skill-building group as part of what staff
indented to be an instructive example, and not as an insult directed at youth in care. All youth report having a good understanding of their treatment
goals and report frequent or daily contact with family and friends.
Program Strengths: The program identified the following strengths regarding each program:
Foundations: Foundations provides a therapeutic environment for youth of all genders. Each youth can have their own room and there is both
inside and outdoor space for youth to utilize. Staff are trained in Trauma Informed Care, Collaborative Problem Solving and Non-Violent Crisis
Intervention so that they can effectively meet the needs of the population being served.
River Rock: River Rock has a structured program that youth respond to relatively well. Prior to the pandemic, we have had consistency of staff
(although staffing shortages makes this hard at times). We work on having good communication which helps our program’s strength. Our staff are
well trained and build rapport with youth fairly quickly. Staff are trained in Trauma Informed Care, Collaborative Problem Solving and Non-Violent
Crisis Intervention so that they can effectively meet the needs of the population being served.
Rising Light: Youth have their own rooms. The smaller population level allows for staff to spend more 1:1 time with the youth. There are many
years of experience within the Rising Light Treatment Team. Staff have been trained in Trauma Informed Care, Collaborative Problem Solving and
Non-Violent Crisis Intervention. Staff focus on building rapport with youth and meeting them where they are at. Consistency and communication
amongst staff are an area of importance within the team to help maintain a supportive, structured, and therapeutic environment. The youth’s
advancement in the program is celebrated with them earning a new bracelet. We also hold graduation ceremonies for youth who have completed
the program.
Program Challenges: The following challenges were identified by the program:
River Rock: Staffing shortages is a huge program challenge. We work with challenging youth and when we have consistent staff and full staff, this
helps. The last year or so, there has been a severe staffing shortage. Another issue we have had challenges with, is medication refills and getting
youth into see a psychiatric prescriber. There are not a lot of providers in the Roseburg area and when youth are referred to us, if they don’t have
refills of their psychotropic medications, it could be weeks before we are able to get them into see a primary care provider who could then refer them
to a medication prescriber. It hasn’t been as big a challenge, but we also run into the challenge of a youth’s insurance not transferring to Douglas
County or the youth has services in their originating county and there becomes an issue when the youth need services in Douglas County.
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Therapy services have been an issue also, as we have lost our contract with CARES. There is not always an available provider in the community
that can see youth that are referred to us.
Rising Light: Rising Light has experienced the same challenges as the River Rock and Foundations programs.
Foundations: The above listed concerns for Rising Light and River Rock are also challenges experienced in Foundations.
Changes that have occurred in the last 2 years as reported by the program:
River Rock: When the COVID-19 pandemic began and with changes in the way youth were/could be referred to the program, we saw a huge
decline in referrals. At various times we would also be on intake freeze due to COVID-19 outbreaks. SB710 also created a significant change. We
were more cautious on accepting youth who previously had behaviors requiring restraints, knowing that we would be liable if anything were to
happen. We also saw a pretty big change in referrals and youth in the program when the QRTP process began. We have had youth placed and
then pulled from programming if they didn’t qualify, but the youth clearly needed BRS level of care.
Rising Light: Rising Light has experienced the same significant changes as the River Rock and Foundations Programs.
Foundations: Foundations has experienced the same changes as mentioned above in regard to referrals, COVID 19, SB 710, and referrals.
Lawsuits: None as reported by the program.
Grievances and complaints filed in the last two years: None as reported by the program.
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report Douglas County Juvenile Department must submit a letter of verification indicating the agency is in
compliance with the specific rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification,
the agency must submit any and all specific documentation requested in the body of this report. The letter of verification and any additional
requested documents can be emailed directly to Mary Torres at mary.torres@dhsoha.state.or.us or sent by regular mail to the following address:
Department of Human Services, Children’s Care Licensing Program
Attn: Mary Torres
201 High St SE, Suite 500
Salem, OR 97301
Exceptions: Over this last licensing period, the program has requested and was granted various age exceptions.
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Standing egress exception was granted the previous licensing period (2020-2022) and will need to re request this egress exception to cover this
licensing period (2022-2024).
Changes in License: The program’s license may experience a change during this next licensing period (2022-2024) with the potential closure of
Foundations. Should this closure come to fruition, the program will alert Licensing and the program’s license will be modified.
Summary of Review
Program and Services Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0011(2) Completed
Program and services are in scope of license X
Governance of the Agency Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0021 Completed
(1)(a) Minimum of 5 board members X
(2)(f) Formally evaluate the exec. Director’s X The Exec. Director’s performance evaluation occurs every
performance annually September.
(2)(g) Approves annual budget X
(2)(h) Obtain and review an annual X
independent financial review or audit of
financial records.
(2)(k) Written quality improvement program X
(2)(l) Meeting minutes X
Executive Director or Program Director Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0021 Completed
(3)(a) knowledge of requirements for X
providing care and treatment appropriate to
programs
(3)(g) Approval from BCU X BCU approval 4/25/22.
Discipline, Behavior Management, and Corrective Action
Yes No N/A Corrective Actions/Comments
Suicide Prevention 413-215-0076 Completed
(3) Agency uses appropriate and positive
methods of behavior management and
X CPI and CPS are utilized by the program.
nationally recognized non-violent crisis
intervention
(3)(b)(C) Agency does not use chemical and
mechanical restraint (excluding medically X
necessary devices/prescriptions)
(3)(c) Agency uses appropriate time-out
rooms (adequate space, heat, light and X
ventilation and is not capable of locking) and
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documents use in child’s record when
applicable
(3)(e) Agency uses seclusion
X
appropriately/consistent with policy
(4) Agency has adequate plan in place to
X
respond to suicidal behavior/warning signs
Contractors (if applicable) Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0061(6) Completed
(a) Agency ensures the contractor meets the
requirements of this rule and Chapter 413 X
division 215
(b)(B) Contract includes the following:
(i) Services provided
(ii) Contractor fees
(iii) Disclosure of information from contractor
to agency
(iv) Lines of authority X
(v) Adherence to rules, including background
check
(vi) Any liability of the agency for acts of the
contractor, rights of indemnity and limitations
on liability
Supplemental Information Provided by Corrective Action
Yes No N/A Corrective Actions/Comments
CCA Completed
Documents as indicated on the form titled
X
“Renewal Licensing Required Documents”
Documents as indicated on form titled
“Required Financial Documents and X
Information”
All required policies and procedures as The policy submitted to cover Conflict of Interest, Policy # A-
identified in the “Umbrella Rules” 10, does not meet licensing rule.
CORRECTIVE ACTION: Create a Conflict-of-Interest policy
that is reflective of the following licensing rule:
413-215-0036 Licensing Umbrella Rules: Conflict of
Interest (Amended 12/01/19)
A child-caring agency must have a conflict-of-interest policy
X
that prohibits preferential treatment of board members,
employees, volunteers, and contributors. The policy must
outline safeguards when the child-caring agency allows dual
relationships, such as employees serving as proctor foster
parents, including the requirement that all material facts of
the conflicted transaction and the direct or indirect interest of
the board member, employee, volunteer, or contributor are
disclosed or known to the board approving the conflicted
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transaction. If circumstances do not permit board approval of
the conflicted transaction, a non-profit child-caring agency
may obtain the approval of the Attorney General or the
Department prior to entering into the transaction.
The submitted Youth and Parent/Guardian Rights (Policy #
CTS-8) is missing required items.
CORRECTIVE ACTION: Revise Policy # CTS-8 that is
reflective of the following licensing rule.
413-215-0046 Licensing Umbrella Rules: Children and
Families Rights Policy and Grievance Procedures
(Amended 1/1/19)
(a) Except as provided in paragraph (B) of this subsection,
the child in care's right to uncensored communication with
legal guardians, caseworkers, legal representatives, and
other persons approved for communication by the legal
guardian or as provided in a court order.
(A) This right cannot be waived, including voluntarily.
Restriction on communication between a child in care and his
or her legal guardian may not be a condition of participation
in the program.
(B) A child-caring agency may place reasonable limits on
communication, but only as provided in the child-caring
agency's policy. Reasonable limits include, but are not limited
to, having set time periods during the day for visitation and
phone calls and imposing moderate limits on the duration of
calls or visits. However, a limitation is not considered
reasonable if it prevents the ability to meaningfully
communicate, such as not allowing contact with a child in
care's attorney during regular business hours.
(b) The child in care's right to privacy.
(c) The child in care's right to participate in service planning
or educational program planning.
(d) The child in care's right to fair and equitable treatment.
(e) The child in care's right to file a grievance (as provided in
section (2) of this rule) if the child in care or family feels that
they are treated unfairly or if they are not in agreement with
the services provided.
(f) The child in care's right to have adequate and personally
exclusive clothing.
(g) The child in care's right to personal belongings.
(h) The child in care's right to an appropriate education.
(i) The child in care's right to participate in recreation and
leisure activities.
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(j) The child in care's right to have timely access to physical
and behavioral health care services.
The existing Grievance Procedure (Policy # CTS-9) requires
revision to meet compliance.
CORRECTIVE ACTION: Revise Policy # CTS-9 that is
reflective of the following licensing rule.
413-215-0046 Licensing Umbrella Rules: Children and
Families Rights Policy and Grievance Procedures
(Amended 1/1/19)
(2) Grievance Procedures.
(a) A child-caring agency must enact and adhere to written
procedures for the children in care and families the child-
caring agency serves to submit a grievance. For an academic
boarding school, this subsection only applies to grievances
about health or safety issues. The child-caring agency must
provide the procedures to each child in care and family. The
procedures must include all of the following:
(A) A process likely to result in a fair and expeditious
resolution of a grievance.
(B) A prohibition of reprisal or retaliation against any
individual who files a grievance.
(C) A procedure to follow, in the event the grievance is filed
against the executive director, that ensures that the executive
director does not make the final decision on the grievance.
(D) The name, address, and phone number of:
(i) A Department licensing coordinator; and
(ii) Any other governmental entities with oversight
responsibilities.
(b) Grievances and complaints filed with the child-caring
agency and all information obtained in their resolution must
be maintained for a minimum of two years and provided to
the Department upon request.
The existing policy related to mandatory child abuse reporting
(Policy# A-17) requires revision to meet compliance.
CORRECTIVE ACTION: Revise the existing policy to include
the following information:
The submitted policy defines each type of abuse. Under ORS
418.257 additional abuse types are listed that are not
reflected in the program’s existing policy. Add missing forms
of abuse and their definition to include abandonment, willful
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infliction of physical pain or injury, verbal abuse, financial
exploitation, involuntary seclusion, wrongful restraint.
In addition, revise policy that is reflective of the following
licensing rule.
413-215-0056 Licensing Umbrella Rules: Policies and
Procedures (Amended 1/1/19)
(1) For each program it is licensed to operate, a licensee
must have and adhere to comprehensive written policies and
procedures that are well organized, accessible, and easy to
use.
(2) In addition to other policies and procedures required by
these rules, the policies, and procedures in section (1) of this
rule must include:
(a) A written policy on mandatory child abuse reporting,
consistent with ORS 418.257, 418.258, 419B.005, 419B.010,
and 419B.015 that includes requirements that child-caring
agency employees, staff, contractors, agents, and proctor
foster parents do all of the following:
(A) Immediately report suspected child abuse directly to the
Department via the child abuse reporting hotline.
(B) Receive child-caring agency-provided training on
mandatory abuse reporting requirements as part of employee
orientation and at least annually thereafter as described in
OAR 413-215-0061.
(C) Receive child-caring agency-provided training on the
definitions of child abuse in ORS 418.257 and 419B.005 that
apply in child-caring agencies.
A policy regarding documenting and reporting critical events
was not submitted for review.
CORRECTIVE ACTION: Submit a copy of this policy. If one
does not exist, generate this policy as outlined by the
following rule:
Licensing Umbrella Rules: Policies and Procedures
(Amended 1/1/19)
(b) A written policy and procedure on documenting, reporting,
and saving information about critical events and other types
of incidents that includes, but is not limited to:
(A) What situations, circumstances, or events warrant a
written report. This must include critical events (see OAR
413-215-0091(11)(b)) but may include additional types of
incidents or events that the agency tracks internally or is
required to provide by other regulatory agencies.
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(B) What information will be included in a written report. This
must include, but is not limited to, the following:
(i) Description of the incident including, but not limited to, any
injury, accident, or unusual incident. If the incident involves a
hold or restraint, whether the child in care was injured or
reported pain or injury.
(ii) Whether the report meets the definition of a critical event
(see OAR 413-215-0091(11)(b)).
(iii) Description of the actions the child-caring agency took in
response to the incident.
(iv) Any children in care involved.
(C) Whether and how a report will be shared. Critical events
must be shared with the child-caring agency's assigned
licensing coordinator (see OAR 413-215-0091(11)(b)) but
other types of reports may be shared with other regulatory
agencies or legal guardians.
(D) How a report will be saved. This must include, but is not
limited to, ensuring the report is placed in the individual child
in care's record if applicable.
Submitted policy regarding personnel (Policy# A-12) requires
revision to meet compliance.
CORRECTIVE ACTION: Revise Policy# A-12 that is
reflective of the following licensing rule.
413-215-0061 Licensing Umbrella Rules: Personnel
(Amended 1/1/19)
(2) Personnel policies of the child-caring agency and its
contractors must include all of the following:
(a) For each staff position, a job title and a written job
description that defines the qualifications, duties, and lines of
authority for the position.
(b) A staff development plan providing for opportunities for
professional growth through supervision, training, and
experience.
(c) Procedures for a written annual evaluation of the work
and performance of each staff member that include provision
for employee participation in the evaluation process.
(d) A description of the termination procedures established
for resignation, retirement, and dismissal.
(e) A written grievance procedure for staff.
The policy submitted regarding privacy (Policy# A-11) is
related to employees and not youth and their families.
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CORRECTIVE ACTION: Submit privacy policy for review. If
a policy does not exist, create one to include what is outlined
in rule.
413-215-0066 Privacy (Amended 06/29/18)
(1) A child-caring agency must have and adhere to a written
policy that addresses protection of the privacy of children and
families the child-caring agency serves or has served.
(2) Except as provided in section (4) of this rule, a child-
caring agency may not disclose any identifying information of
a child in care, including a picture, without first obtaining the
written consent from the child's parents or legal guardians.
(3) A child-caring agency must ensure the privacy of all
information that identifies a child in care or family the child-
caring agency serves. A child-caring agency may not
disclose such information without proper written consent or
as otherwise allowed by law.
(4) A person making a report of abuse as required in ORS
418.258 and 419B.010 may include references to otherwise
confidential information for the sole purpose of making the
report.
The existing Behavior Management Policy (Policy # CTS-1)
requires revision to meet compliance.
CORRECTIVE ACTION: Revise Policy # CTS -1 that is
reflective of the following licensing rule.
413-215-0076 Licensing Umbrella Rules: Discipline,
Behavior Management & Training, and Suicide
Prevention (Excluding Adoption Agencies) (Amended
09/01/2021)
(b) The discipline and behavior management policies and
procedures must prohibit the following:
(A) Spanking, hitting, or striking with an instrument.
(B) Committing an act designed to humiliate, ridicule, or
degrade a child in care or undermine the self-respect of a
child in care.
(C) Punishing a child in care in the presence of a group or
punishment of a group for the behavior of one child in care.
(D) Depriving a child in care of food, clothing, shelter,
bedding, rest, sleep, toilet access, or parental contact.
(E) Assigning extremely strenuous exercise or work or
requiring a child in care to spend prolonged time in one
position likely to produce unreasonable discomfort.
(F) Using restraint or involuntary seclusion as discipline.
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(G) Permitting or directing a child in care to punish another
child in care.
(H) Using any other kind of harsh punishment.
(I) Denying a parent, guardian, or sibling the right to visit or
communicate with a child in care solely as a disciplinary
measure against the child in care.
(J) Aversive conditions, which includes, but is not limited to,
any technique designed to or likely to cause a child physical
pain, the application of startling stimuli, and the release of
noxious stimuli or toxic sprays, mists, or substances in
proximity to the child in care.
(3) Behavior Management.
(C) Use of restraints, if applicable.
(i) Chemical restraint, meaning the administration of
medication for the management of uncontrolled behavior, is
prohibited. Chemical restraint is different from the use of
medication for treatment of symptoms of severe emotional
disturbances or disorders.
(ii) Mechanical restraint, meaning the use of any physical
device to involuntarily restrain the movement of a child in
care as a means of controlling his or her physical activities, is
prohibited.
(d) Training.
(A) Only child-caring agency staff and proctor foster parents
who have been trained in a nationally recognized nonviolent
crisis-intervention system consistent with OAR 413-215-0077
may use restraint or involuntary seclusion and only, when
necessary, as a last resort to prevent a child in care from
inflicting harm to self or others.
(B) Any use of restraint or involuntary seclusion must be
conducted within the parameters of the nationally recognized
system in which the child-caring agency staff or proctor foster
parent is trained and must meet the requirements and
provisions described in OAR 413-215-0077.
(C) Any child-caring agency staff or proctor foster parent
utilizing restraint or involuntary seclusion must be trained on
the type of restraint or involuntary seclusion used, and the
restraint or involuntary seclusion must be within the
parameters of the nationally recognized system in which the
staff or proctor foster parent is trained and must be consistent
with OAR 413-215-0077.
(e) Review. The policies of the child-caring agency must
require that whenever a restraint is used on a child in care
more than two times in seven days, there is a review by the
executive director, the director's designee, or a management
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team to determine the suitability of the program for the child
in care, whether modifications to the child in care's plan are
warranted, and whether staff need additional training in
alternative therapeutic behavior management techniques.
The child-caring agency must take appropriate action
indicated by the review.
Youth Searches policy (Policy# YC-1) requires revision to
meet compliance.
CORRECTIVE ACTION: Revise Policy# YC-1 that is
reflective of the following licensing rule.
413-215-0079 Licensing Umbrella Rules: Safety (Adopted
09/01/2021)
(2) Searches. If a child-caring agency carries out searches on
children in care or visitors, the child-caring agency must have
written policies and procedures that, at a minimum, comply
with all of the following:
(a) A prohibition on strip searches.
(b) A prohibition on body cavity searches.
(c) Requirement that searches will be conducted in the least
intrusive manner possible for the type of search being
conducted.
(d) Requirement that pat down searches of children in care
will only be conducted when necessary to discourage the
introduction of contraband, or to promote the safety of staff
and other children in care and will only be conducted as
follows:
(A) By staff trained in proper search techniques;
(B) By a staff member of the same sex as the child in care
being searched, and in the presence of another staff
member;
(C) The child in care must be told the child is about to be
searched;
(D) The child in care must be asked to remove all outer
clothing (gloves, coat, hat, and shoes) and empty all pockets;
(E) The staff member must then pat the clothing of the child
in care using only enough contact to conduct an appropriate
search;
(F) If the staff detects anything unusual, the child in care
must be asked to identify the item, and appropriate steps
must be taken to remove the item for inspection;
(G) If the child in care refuses to comply, the executive
director or designee must be notified immediately and be
responsible to resolve the matter; and
14
(H) All searches must be documented in writing.
(e) Policy regarding obtaining appropriate consents for
searches.
(f) If the child in care refuses to comply with a requirement of
the search, the program must follow established policies to
determine if the child in care can be refused admission to or
discharged from the program.
(g) Information regarding any personal or room searches and
protocols for confiscation of contraband items, including the
notification of law enforcement if illegal contraband is
discovered. This information will include the procedures and
rationales of the child-caring agency for any program-initiated
room or body search.
Use of Restraint and Seclusion policy (Policy# CTS-22)
requires revision to meet compliance.
CORRECTIVE ACTION: Revise Policy# CTS-22 to include
the following item as in rule.
413-215-0077 Licensing Umbrella Rules: Restraints and
Involuntary Seclusion (Adopted 09/01/2021)
(e) Limitations. The child-caring agency must have a policy
that prohibits the application of a nonviolent restraint to a
child in care who has a documented physical condition that
would contraindicate the use of that particular restraint,
unless a qualified medical professional has previously and
specifically authorized its use in writing for the child in care.
Documentation of the authorization must be maintained in the
child of care’s record.
All required policies and procedures as
identified in “Agency Type Specific Rules”
Physical Plant Corrective Action
Yes No N/A Corrective Actions/Comments
Completed
413-215-0046(3)(a) Foster Rights Posted (if X
children in DHS custody)
413-215-0051(1) Sufficient safe space, X Room #3 at Rising Light has profanity written on walls.
equipment, and office equipment Room #4 at River Rock has multiple holes in the wall.
413-215-0091(12) License is posted in X Room #2 at River Rock door and door frame damaged
common area at each facility River Rock has soaked towels outside shower stall as
413-215-0001(5)(d), 0516(4(a)(I) & 0521(1) X makeshift bath mat
Adequate furnishings and personal items Bathroom at River Rock has a hole in the wall
413-215-0511(2)(a) &(c) Buildings are X
smoke free, clean and in good repair CORRECTIVE ACTION:
413-215-0511(2)(d) Rooms are free of X Wipe clean or paint over profanity.
harmful drafts, odors, and excessive noise Repair holes in the walls.
15
413-215-0511(2)(e) Rooms are adequate in X Replace or repair door and door frame
size and arrangement Develop a plan where towels are picked up from the floor to
413-215-0511(2)(f) System provides a X avoid saturated towels from being left on floors for extended
continuous supply of hot and cold water to periods of time.
taps located throughout the facility Repair hole in wall in bathroom
413-215-0511(2)(h) Building is well X
ventilated and room temperature is within a
normal comfort range
413-215-0516(1) All parts of the facility X Room #10 at River Rock noticeably cool during the facility’s
ensure the safety of children tour.
CORRECTIVE ACTION: Assess youth’s comfort level with
the room’s temperature and evaluate what maybe causing
the noticeable difference in room temperature to ensure a
normal comfort range.
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
Bedrooms 413-215-0516(3) Completed
(a) Adequate furnishings and personal items X
(b) Separate from rooms used for dining, X
living, laundry, kitchen, and storage
(c) Outside room with window allowing X Bedrooms at River Rock and Rising Light have either no or
egress from building fixed windows that require an exception from Licensing.
(d) Ceiling at least 90 inches X
(e) Minimum 60 SF per bed X CORRECTIVE ACTION: Submit new window exception for
(f) No more than 25 if dorm style X this next licensing period (2022-2024).
(g) Permanently wired fixtures X
(h) Window covering X
Rising Light has single occupancy bedrooms. River Rock
(i) Beds are 3 feet apart and maintained to X
has two double occupancy bedrooms but is moving to single
ensure safety
occupancy bedrooms.
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
Bathrooms 413-215-0516(4) Completed
(a)(A)&(B) 1:8 ratio for toilets and sinks X
(a)(D) Hot and cold running water, soap, and X
approved hand drying options
(a)(E) 1:10 ratio for shower or bathtub X
(a)(E) Individual privacy X
(a)(F) Window covering X Bathrooms at River Rock and Rising Light have no windows.
(a)(G) Permanently wired fixtures X
(a)(H) Adequate ventilation X
REPEAT FINDING from 2021 Unannounced Visit
(b)&(c) Wooden racks on floors are X
Bathroom at River Rock continues not to have a source of
prohibited and impervious shower mats are
ventilation.
disinfected & dried daily
16
CORRECTIVE ACTION: Address lack of ventilation during
the facility’s current remodel.
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
Kitchen 413-215-0516(6) Completed
(a) Used exclusively for storage, food X
preparation, dish washing and activities
related to eating
(b) Walls, floors are easily cleanable X
(c) Equipment and utensils are easily
cleanable, durable, nontoxic, and kept clean
(e) Equipment is easy to clean beneath, X
between and behind
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0516 Completed
(2) There is a separate living room or lounge X
area – 15 SF minimum per child
(5) There is a separate dining room with X
capacity for ½ of children in care and 15 SF
per child in care
(7) Laundry is separate from living areas, X
kitchen, and dining
(8) Separate storage areas are provided for X
food, kitchen supplies, utensils, clean linens,
soiled linens and clothing, cleaning supplies
and equip, poisons, chemicals, outdoor
recreational and maintenance equipment
(9) Outdoor activity area is protected from X
vehicles and other hazards and of a size and
availability appropriate to the age and needs
of children in care
(11) & 413-215-0076(3)(c)(C)Time out rooms X
have adequate space, heat, light and
ventilation and is not capable of locking
Furnishings and Personal Items Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0521 Completed
(1) There is a bed with frame, clean mattress X
and pillow and personal storage (dresser,
closet)
(2) Linens are in good repair. There is a X
waterproof mattress cover or mattress.
Linens are appropriate and towels and
washcloths are provided
(3) Bedding is changed weekly or when X
soiled
17
(4)&(5) Personal hygiene supplies and X
appropriate clothing are provided
Food Services Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0536(1)&(2) Completed
(1)(a) Meals are arranged daily, consistent X
with normal mealtimes that occur during the
hours of operation
(1)(b) Menus are prepared in advance in X
accordance with USDA guidelines, provide a
variety of foods and are adjusted for
seasonal changes.
(1)(b) Menus are kept for at least 6 months X
(1)(c) Drinking water is freely available X
(2)(a) Food is stored, prepared & served in a X
sanitary manner
(2)(c) & (d) Food products are obtained from X
commercial suppliers (exception of fruits &
vegetables), unpasteurized juice is
prohibited, and only Grade A pasteurized
and fortified milk in appropriate container.
Safety Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0541 Completed
(2)(a) Written emergency plan X
(2)(b) Telephone numbers for local police X
and fire are posted near all telephones
(2)(c) Operative flashlights sufficient in X
number are readily available to staff
(3)(a) Evacuation drill occurs monthly under X
varying conditions, is retained 2 yrs., and
contains;
(A) identify of person conducting drill
(B) date & time
(C) notification method
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
Safety – Transportation Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0541 Completed
(5)(b) Vehicle has insurance policy, is smoke X Black Impala (without cage) – driver’s seat has no back cover
free, safe operating condition, and has first
aid kit and fire extinguisher 2-A:10-BC 15 passenger van has no 1st aid kit and padlock key to
emergency box is missing
18
14 passenger van 2021 has expired registration
CORRECTIVE ACTION: Make necessary repairs to the
driver’s seat in the black Impala. Ensure that the 15-
passenger van has a 1st aid kit and that a lock to the padlock
is placed on the van’s key chain. Renew the registration for
the 2021 14 passenger van. Place insurance and accident
packet in each vehicle.
Medication Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0551 Completed
(3)&(7)(e) Medications have a prescription X
and are stored in the original container with
prescription label
(4)&(5) Herbal supplements and remedies, X
medical treatments, special diets, physical
therapy, physical aides, or limitations have a
written order signed by a physician or
qualified medical professional.
(7)(c) Medications are inaccessible to X
children
(8) Medications are disposed in accordance X
with state and federal law
(9) Written record of the disposal of X
medications is maintained and includes:
(a) description and amount
(b) name
(c) reason
(d) method
(e) staff & witness signature
(10) Written record of the administration of X Medication Administration Records (MARs) reviewed at
medication includes: Rising Light and River Rock reflected several times where
(a) name missed medication was not appropriately documented.
(b) description
(c) dates and times CORRECTIVE ACTION: Determine if the missed
(d) missed doses documentation is related to a specific staff member and
(e) medication disposed follow up with additional training. Remind all staff the
(f) method of administration importance of medication documentation.
(g) ID of person administering
(h) possible adverse reactions
(i) medication taken outside facility
Extracurricular, Enrichment, Cultural &
Corrective Action
Social Activities Yes No N/A Corrective Actions/Comments
Completed
413-215-0554
19
(2) Children have ongoing opportunities to X
participate in at least one age-appropriate or
developmentally appropriate activity
Minimum Staffing Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0561 Completed
(1)&(2) Supervision is adequate for the type X
of program, location, age and type of
children, ability of supervisor to respond,
electronic back-up systems.
Minimum ratios are maintained:
Under 30 months of age: 1:4
30 months to ˃ 6 yrs. or non-ambulatory: 1:6
Ages 6 and older: 1:7
Overnight (staff awake)
1:10
(4)(a) When one staff on duty, there is X
additional staff immediately available with
max response time of 30 minutes
(5) There is at least one on-site employee X
authorized to apply the reasonable and
prudent parent standard
Separation of Residents Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0566 Completed
(1) Children are in separate bedrooms than X
adults, unless parent and child, or there is
written approval from guardian/parent and
licensing coordinator
(2) There is adequate supervision of children X
if both males and females are served by the
program
Personnel Files Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0061 Completed
Staff Name/Position X
(3)(g) Date of Hire X
20
(3)(a) record of education, training, and Reference checks are completed during the extensive
X
previous employment background checks completed for all county employees.
This information is kept separate from the personnel files.
(1)(b) & (3)(b) reference checks completed
X
and documented
(1)(a) & (3)(c) Background check completed
X
Four out of the five personnel files reviewed did not
and documented
document the completion of annual evaluations.
(3)(d) Annual performance evaluations X
CORRECTIVE ACTION: Ensure that annual performance
(3)(f) Record of personnel actions X
evaluations are completed and maintained in their respective
(3)(g) Termination date, reason for
X
personnel files from this point forward.
termination
(3)(h) Current job description (1)(c)
Employee meets minimum qualifications X
stated in current job description
New Employee Orientation – Umbrella
Corrective Action
Requirements (30 days) Yes No N/A Corrective Actions/Comments
Completed
413-215-0061(4)
(a) Agency policies and procedures X
(b) Ethical and professional guidelines X
(c) Organizational lines of authority X
(d) Attributes of population served X
(e) & (5)(a) to (c) Mandatory reporting that New Employee Orientation for three staff members could not
includes: be verified during the audit of personnel files.
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter 106, CORRECTIVE ACTION: Submit a plan as to how new
X
section 36 employee training will be provided and appropriately
(b) legal responsibility to immediately report documented from this point forward.
(c) legal responsibility to report is personal to
the employee
(f) Privacy laws X
(g) Emergency procedures X
New Employee Orientation – Residential
Corrective Action
(30 days) Yes No N/A Corrective Actions/Comments
Completed
413-215-0556
(1)(a) Discipline and behavior management
including de-escalation, crisis prevention,
positive behavior management, and X
disciplinary techniques that are non-punitive
in nature
(1)(b) Restraint and seclusion (if applicable) X
21
Ongoing Training Corrective Action
Yes No N/A Corrective Actions/Comments
Completed
413-215-0536(2)(b) Employees who handle X
food served to children have a valid food
handler’s card Four out of five personnel files did not reflect the completion
of required ongoing training in these areas.
413-215-0541(5)(a) Employees transporting
children have: current driver’s license,
CORRECTIVE ACTION: Submit a plan as to how this
insurance, trained in emergency procedures X
training will be provided and appropriately documented from
and behavior management, and training for
this point forward.
15+ passenger vans if applicable)
413-215-0556(2)(a) Environmental
X
emergencies
413-215-0556(2)(b) Universal Precautions X
413-215-0556(2)(c) Discipline and Behavior
X
Management
413-215-0556(3) Staff providing direct care
must maintain current CPR/First Aid X
certification
413-215-0556(4) Designated staff authorized
to apply reasonable and prudent parent The program’s counselors are the designated staff members
X
standard are trained in application of the trained in the application of prudent parent standard.
standard
413-215-0061(5) Mandatory reporting
(annually) that includes:
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter 106,
X
section 36
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
Comments:
22
Children’s Records Corrective Action
Yes No N/A Corrective Actions/Comments
Completed
Health Services
413-215-0546
(2) Medical history obtained within 30 days
(significant findings, current immunizations,
history of surgical procedures-health issues- X
injuries, allergies, dental, vision, hearing,
Youth files reviewed do not reflect the documentation of age-
behavioral health, and physician orders)
appropriate instruction.
(2)(e) Documentation of age-appropriate
instruction – pregnancy prevention, nutrition,
CORRECTIVE ACTION: Develop a procedure where age-
prevention of HIV & AIDS, and prevention X
appropriate instruction is documented in the youths’ files
and treatment of sexually transmitted
from this point forward.
disease
(4)(a) to (f) Medical exams (3 in first year of
life, 2,4,6,9,14) X
Consents Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0576(1) Completed
(a) Provide routine and emergency medical Consent allowing access could not be located in the youth
X
care files.
(b) Use the discipline and behavior
X CORRECTIVE ACTION: Add required consent to intake
management system
packet. See following rule for reference: 413-215-0576
(c) Use restraint or seclusion (if applicable).
Consents, Disclosures, and Authorizations (Amended
Must specify the reasons for the intervention X 09/01/2021)
and how staff are trained and supervised
(1) Consents. For each child in care in placement with a
(d) Restrict contact with persons outside of residential care agency, the residential care agency must
X
the agency ensure that a parent or legal guardian signs a consent that
authorizes the residential care agency to undertake each of
(e) Allow access as defined in 413-215-0091
X the following: (e) To allow access to a child in care as
& 0101
required in ORS 418.305 and OAR 413-215-0091 and 413-
(f) Impose a dress code X 215-0101.
(g) Apply the reasonable and prudent parent Consent imposing a dress code could not be located in the
X
standard youth files.
23
CORRECTIVE ACTION: Add required consent to intake
packet that the program may impose a dress code during a
youth’s stay.
Consent applying reasonable and prudent parent standard
could not be located in the youth files.
CORRECTIVE ACTION: Add required consent to intake
packet. See following rule for reference: 413-215-0576
Consents, Disclosures, and Authorizations (Amended
09/01/2021)
(1) Consents. For each child in care in placement with a
residential care agency, the residential care agency must
ensure that a parent or legal guardian signs a consent that
authorizes the residential care agency to undertake each of
the following: (g) To apply the reasonable and prudent parent
standard to determine whether the child in care is allowed to
participate in age-appropriate or developmentally appropriate
activities including extracurricular, enrichment, cultural, and
social activities.
Disclosures
Corrective Action
413-215-0576(2) Parent/guardian has Yes No N/A Corrective Actions/Comments
Completed
acknowledged in writing:
(a) Information regarding personal or room Disclosure regarding personal and room searches and
searches and protocols for confiscation of X protocols for confiscation of contraband could not be located
contraband in the youth files.
(b) Statement of Rights of Children and
X
Parents/Guardians CORRECTIVE ACTION: Add required disclosure to intake
packet. See rule for reference: 413-215-0576 Consents,
Disclosures, and Authorizations
(Amended 09/01/2021) (2) Disclosures to parent or legal
guardian. At the time a residential care agency takes a child
in care into placement, the residential care agency must
ensure that each parent or legal guardian of the child in care
receives and acknowledges in writing the receipt of each of
the following: (a) Information regarding any personal or room
(c) Any policies and procedures upon
X searches and protocols for confiscation of contraband items,
request
including the notification of law enforcement if illegal
contraband is discovered. This information will include the
procedures and rationales of the residential care agency for
any program-initiated room or body search.
Disclosure stating that policies and procedures will be
provided upon request.
24
CORRECTIVE ACTION: Add required disclosure to intake
packet. See rule for reference: 413-215-0576 Consents,
Disclosures, and Authorizations (Amended 09/01/2021)
(2) Disclosures to parent or legal guardian. At the time a
residential care agency takes a child in care into placement,
the residential care agency must ensure that each parent or
legal guardian of the child in care receives and
acknowledges in writing the receipt of each of the following:
(c) The residential care agency will make any written policy
or procedure pertaining to program services available for
review by the child in care, parent, or legal guardian, upon
request.
Authorizations Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0576(3) Completed
(a) Disclose or exchange information with
X
others
(b) Child specific visitors X Two out the five youth files reviewed did not have activity
specific authorizations.
(c) Visitation resources are pre-approved X
(d) Activity specific authorizations are pre- CORRECTIVE ACTION: Ensure that this authorization is
approved to allow children to participate in obtained and kept in the respective youth file from this point
potentially hazardous activities, including but X forward.
not limited to using motorized yard
equipment, swimming, and horseback riding.
Information about Children in Care
Corrective Action
413-215-0581(1) Summary sheet contains Yes No N/A Corrective Actions/Comments
Completed
the following:
(a)The name, gender, date of birth, religious Courtesy reminders were made to the program to
X
preference, and previous address consistently document youths’ date of admission as well as
(b) Name and location of previous and who specifically has legal custody of the youth (i.e., which
X
current school agency or which listed parent).
(c) Date of admission X
(d) Legal custody X
(e) The name, address, and telephone
number of:
(A) The child in care's parents.
(B) The child in care's legal guardian, if
different than the parents, and a copy of
X
the document that provides for his or her
authority over the child in care.
(C) Other persons significant to child
(D) Other professionals to be involved in
service planning (if applicable)
25
Service Planning Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0581(2) Completed
(b) Intake document is completed the date
child accepted into care (emergency X
placement 48 hours)
(d) Assessment is completed within 30 days
and contains relevant historical info., current
behavioral observations, identified need for X
services, and how agency will provide
services
(e) (A)&(B) Service plan within 60 days
(parent, guardian and child actively
involved). Describes how child’s issues will X
be addressed, anticipated outcomes, and
reviewed by child and guardian/parent.
(e)(C)&(D) Service plan is reviewed quarterly
and revised when information indicates other X
services should be provided
Case Management Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0581(3) Completed
(a) Services are documented, progress
X
toward achieving goals is tracked
(b)-(d) discharge planning and instructions X
(f) Incident Reports X
Financial Records Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0581(4) Completed
Records contain date, amount, source,
X
purpose, signatures
Personal Possessions Records Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0581(5) Completed
Individual written inventory of all personal
possessions is maintained and updated as X
needed
Records and Documentation Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0071 Completed
(1) Stored safely X
(2) Permanent, legible, dated, and signed X
26
(3)&(4) Uniform in organization, readily
identifiable and accessible, current, and
X
complete, containing all required info. No
eraser tape or white out.
(7) Permanent registry for each child
includes:
Name
Gender
X
Birth date
Names, addresses of parents or guardians
Dates of admission
Placement upon discharge
Comments:
Licensing Coordinator’s Signature: ________________________ Date: ___ _6_/3_/_2_2_ __________
5-30-2022
Manager Review: ______________________________________ Date: __________________
27

report_type: License Renewals

licensing_coordinator: Mary Torres

other_regulatory_agencies: Oregon Department of Human Services (ODHS) Child Welfare - Treatment Services, Oregon Health Authority (OHA), Joint Commission, Oregon Health Authority (OHA)

program_description:
As shared by the program, Foundations, River Rock and Rising Light are Qualified Residential Treatment Programs
(QRTP) as defined under the federal Family First Prevention Services Act. The sites are also approved by ODHS Child Welfare to provide Behavior
Rehabilitation Services (BRS) Residential, Intensive Behavioral Support.The sites were accredited by the Joint Commission in 2020. Foundations
serves all genders ages 12-16, River Rock also serves all genders, but their age range is 13-17. Rising Light serves female youth 12-18 who are
high risk, high acuity and/or victims of the Commercial Sexual Exploitation of Children (CSEC). All facilities provide staff-secure residential services
and/or to provide Individualized Service Plans to youth requiring stabilizations services. The programs provide gender-affirming and inclusive
environment for youth who cannot presently live safely in the community to receive services aimed at developing resiliency, self-direction, and
healthy interdependence in a social setting. Rising Light's treatment model is Collaborative Problem Solving and their treatment environment
espouses the evidence based My Life, My Choice CSEC Prevention and Recovery Curriculum. Both River Rock and Foundations' treatment model
is Collaborative Problem Solving and their treatment environment blends elements of the Sanctuary Model and Restorative Justice. We strive to see
the best in each youth who crosses our path and as such, we assume positive intent.

program_services: BRS Residential Services - Intensive Behavioral Support - Qualified Residential Treatment Program (QRTP)

capacity_age_range: Foundations Facility: 9 youth, ages 12 - 16 River Rock Facility: 12 youth, ages 13 - 17 Rising Light Facility: 8 youth, ages 12 - 18

average_length_of_stay: Foundations: 3 - 6 months River Rock: 3 - 6 months Rising Light: 4 - 6 months

interviews_observations:
Licensing met with the program's management team at the beginning of the two-day review to include the Assistant
Director, Program Managers and Residential Referral and Admissions Coordinator.
In conversation, the program reports feeling the long-term effects of COVID to include staffing issues. Initial recruitment remains difficult for the
program. Perspective applicants, who generally surface once every 2 months, are only interested in day shifts, Monday through Friday. There is no
interest in swing or graveyard. The program reports having temp on-call positions open for the last 2 years with no interest. Since COVID, the
program has lost 10 to 12 full-time employees, three of those positions being from Foundations. Despite this, the program recently hired two new
employees. A new union contract assisted and provided an increase in pay scale for existing employees. Retention efforts were also bolstered with
money left over from a Child Welfare workforce grant used to alleviate student loan debt for current employees. As a result of the ongoing staffing
issues, the program is considering the permanent closure of Foundations. At the end of December 2021, Foundations' youth were consolidated into
the River Rock facility. Should Foundations close, the program would be considered fully staffed with its' existing workforce. The county would
reabsorb the building and could easily repurpose the building. Some ideas include an employee daycare or cafeteria. With the pending closure of
Foundations, the Child Welfare contract will need to be renegotiated on July 1, 2022. Child welfare contracts with Douglas County for 29 beds. The
2
current census is 14 youth. The renegotiation of this contract will consequently result in fewer beds. Moving forward, the program would like to
house 13 4o 14 youth at River Rock between the ages of 13 and 17. Rising Light would stay at 8 youth, ages 12 to 18. The day of the tour, River
Rock was going through a remodel. This renovation would add more bedrooms. Currently, the building has 11 bedrooms. There are plans to add
space to increase capacity to 13 or 14 youth, each having their own room.
The following information was shared and gathered over the review process.
- Aside from staffing, the impact of COVID is reflected in the training documentation. Management is confident that training was occurring on
an individual basis, but was not routinely documented. In addition, a reassignment of duties made it difficult to tracking training.
- Management expressed appreciation of the positive experience of the current management team. All three, Program Managers offer strong
leadership and coaching to their staff.
- Recent relations with law enforcement were strained due to the influx of calls related to difficult youth. The relationship is on better terms.
- The program is moving to a new electronic filing system called Blue Step. This filing system will assist with human resources, financial
tracking and has the capability to allow caseworkers to remote in and review their youth's electronic file.
- Rising Light recently hired a second Residential Counselor.
- The program received new vehicles to include three 15-passenger vans, one 14-passenger van, one 7-passenger van, and 2 Impalas. All
staff are trained in the transportation of youth.
A couple of months ago, River Rock lost their on-site therapist. The therapist's parent agency grew shorthanded and had the therapist return to
their main office. This therapist continues to see Douglas County youth that were already established with her. Youth that arrive to the program
without an established provider are referred to Adapt counseling services. The program makes every effort to maintain youth with their established
mental health providers and will facilitate Zoom and telehealth meetings for continuity of care.
Youth attend school off site. The program's relationship with Horizon, Horizons, an off-site comprehensive educational setting specifically designed
to meet the needs of traumatized, attachment, and disrupted youth, remains positive. The school recently had two teachers leave, but there still
remains an instructor available for youth. Both River Rock and Rising Light send staff members to be with youth during the school day. River Rock
sends two to three staff members, and Rising Light sends one to two staff members during school hours. Staff transport youth back and forth from
school.
During the review, seven youth, randomly selected from all three programs, were interviewed. All youth report positive interactions with staff on a
one-on-one basis. However, there was some running themes that were brought to light during the interview. Youth report reacting negatively when
staff verbally threatened to write up a "behavioral report," report back to their POs or take away privileges, as leverage to earn compliance from
youth. Discussion regarding this was held with the management team during the debrief. It was explained by the Program Managers that staff have
been previously discouraged from viewing and utilizing a behavioral report as a punishment. A behavioral report is designed to initiate a "restoration
agreement" between youth and staff. There was conversation about possibly encouraging staff to focus on the restoration aspect and less on the
behavioral report. Several youths also report staff using inappropriate language when addressing youth. Youth were clear that the inappropriate
language is not directed at youth, but rather, used in general speech. It was also reported that staff are inconsistent when it comes to gown and
3
mouth searches. Transgender youth share negative experiences within the milieu to include name calling, teasing, and bullying. Youth went on to
say that staff could intervene quicker in these types of situations and have better follow through with the offending. All youth were able to identify a
number of staff who they felt comfortable with talking to should they have any outstanding issue or concern. Strengths identified by the youth
include the number of outings, youth having their own room, and the positive relationships established with their assigned counselors. Other
strengths are that staff "are there" for youth, and that the milieu is more stable now that the younger kids are gone. Areas for improvement or
change identified by youth include staff being more consistent in searches, lessening the "attitude and tone" used by staff, facility cleanliness, the
use of more rugs, comfortable couches, and chairs to make River Rock feel more "homey," staff refraining from cursing, using the N-word, and not
antagonizing youth. The use of the N-word was described as occurring in the context of a counseling or skill-building group as part of what staff
indented to be an instructive example, and not as an insult directed at youth in care. All youth report having a good understanding of their treatment
goals and report frequent or daily contact with family and friends.

program_strengths:
The program identified the following strengths regarding each program:
Foundations: Foundations provides a therapeutic environment for youth of all genders. Each youth can have their own room and there is both
inside and outdoor space for youth to utilize. Staff are trained in Trauma Informed Care, Collaborative Problem Solving and Non-Violent Crisis
Intervention so that they can effectively meet the needs of the population being served.
River Rock: River Rock has a structured program that youth respond to relatively well. Prior to the pandemic, we have had consistency of staff
(although staffing shortages makes this hard at times). We work on having good communication which helps our program's strength. Our staff are
well trained and build rapport with youth fairly quickly. Staff are trained in Trauma Informed Care, Collaborative Problem Solving and Non-Violent
Crisis Intervention so that they can effectively meet the needs of the population being served.
Rising Light: Youth have their own rooms. The smaller population level allows for staff to spend more 1:1 time with the youth. There are many
years of experience within the Rising Light Treatment Team. Staff have been trained in Trauma Informed Care, Collaborative Problem Solving and
Non-Violent Crisis Intervention. Staff focus on building rapport with youth and meeting them where they are at. Consistency and communication
amongst staff are an area of importance within the team to help maintain a supportive, structured, and therapeutic environment. The youth's
advancement in the program is celebrated with them earning a new bracelet. We also hold graduation ceremonies for youth who have completed
the program.

program_challenges:
The following challenges were identified by the program:
River Rock: Staffing shortages is a huge program challenge. We work with challenging youth and when we have consistent staff and full staff, this
helps. The last year or so, there has been a severe staffing shortage. Another issue we have had challenges with, is medication refills and getting
youth into see a psychiatric prescriber. There are not a lot of providers in the Roseburg area and when youth are referred to us, if they don't have
refills of their psychotropic medications, it could be weeks before we are able to get them into see a primary care provider who could then refer them
to a medication prescriber. It hasn't been as big a challenge, but we also run into the challenge of a youth's insurance not transferring to Douglas
County or the youth has services in their originating county and there becomes an issue when the youth need services in Douglas County.
4
Therapy services have been an issue also, as we have lost our contract with CARES. There is not always an available provider in the community
that can see youth that are referred to us.
Rising Light: Rising Light has experienced the same challenges as the River Rock and Foundations programs.
Foundations: The above listed concerns for Rising Light and River Rock are also challenges experienced in Foundations.

lawsuits: None as reported by the program.

grievances_and_complaints: None as reported by the program.

changes_in_license:
The program's license may experience a change during this next licensing period (2022-2024) with the potential closure of
Foundations. Should this closure come to fruition, the program will alert Licensing and the program's license will be modified.

excerpt:
All required policies and procedures as
identified in the “Umbrella Rules” The policy submitted to cover Conflict of Interest, Policy # A-
10, does not meet licensing rule.
CORRECTIVE ACTION: Create a Conflict-of-Interest policy
that is reflective of the following licensing rule:
413-215-0036 Licensing Umbrella Rules: Conflict of
Interest (Amended 12/01/19)
A child-caring agency must have a conflict-of-interest policy
that prohibits preferential treatment of board members,
employees, volunteers, and contributors. The policy must
outline safeguards when the child-caring agency allows dual
relationships, such as employees serving as proctor foster
parents, including the requirement that all material facts of
the conflicted transaction and the direct or indirect interest of
the board member, employee, volunteer, or contributor are
disclosed or known to the board approving the conflicted (H) All searches must be documented in writing.
(e) Policy regarding obtaining appropriate consents for
searches.
(f) If the child in care refuses to comply with a requirement of
the search, the program must follow established policies to
determine if the child in care can be refused admission to or
discharged from the program.
(g) Information regarding any personal or room searches and
protocols for confiscation of contraband items, including the
notification of law enforcement if illegal contraband is
discovered. This information will include the procedures and
rationales of the child-caring agency for any program-initiated
room or body search.
Use of Restraint and Seclusion policy (Policy# CTS-22)
requires revision to meet compliance.
CORRECTIVE ACTION: Revise Policy# CTS-22 to include
the following item as in rule.
413-215-0077 Licensing Umbrella Rules: Restraints and
Involuntary Seclusion (Adopted 09/01/2021)
(e) Limitations. The child-caring agency must have a policy
that prohibits the application of a nonviolent restraint to a
child in care who has a documented physical condition that
would contraindicate the use of that particular restraint,
unless a qualified medical professional has previously and
specifically authorized its use in writing for the child in care.
Documentation of the authorization must be maintained in the
child of care’s record.

excerpt:
Foster Rights Posted (if
children in DHS custody) Room #3 at Rising Light has profanity written on walls.
Room #4 at River Rock has multiple holes in the wall.
Room #2 at River Rock door and door frame damaged
River Rock has soaked towels outside shower stall as
makeshift bath mat
Bathroom at River Rock has a hole in the wall
CORRECTIVE ACTION:
Wipe clean or paint over profanity.
Repair holes in the walls.

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

excerpt:
Rooms are adequate in
size and arrangement Replace or repair door and door frame
Develop a plan where towels are picked up from the floor to
avoid saturated towels from being left on floors for extended
periods of time.
Repair hole in wall in bathroom
Room #10 at River Rock noticeably cool during the facility’s
tour.
CORRECTIVE ACTION: Assess youth’s comfort level with
the room’s temperature and evaluate what maybe causing
the noticeable difference in room temperature to ensure a
normal comfort range.

excerpt:
Building is well
ventilated and room temperature is within a
normal comfort range

excerpt:
(a) Adequate furnishings and personal items Bedrooms at River Rock and Rising Light have either no or
fixed windows that require an exception from Licensing.
CORRECTIVE ACTION: Submit new window exception for
this next licensing period (2022-2024).
Rising Light has single occupancy bedrooms. River Rock
has two double occupancy bedrooms but is moving to single
occupancy bedrooms.

excerpt:
(c) Outside room with window allowing
egress from building

excerpt:
(a)(H) Adequate ventilation CORRECTIVE ACTION: Address lack of ventilation during
the facility’s current remodel.

excerpt:
(5)(b) Vehicle has insurance policy, is smoke
free, safe operating condition, and has first
aid kit and fire extinguisher 2-A:10-BC Black Impala (without cage) – driver’s seat has no back cover
15 passenger van has no 1st aid kit and padlock key to
emergency box is missing 14 passenger van 2021 has expired registration
CORRECTIVE ACTION: Make necessary repairs to the
driver’s seat in the black Impala. Ensure that the 15-
passenger van has a 1st aid kit and that a lock to the padlock
is placed on the van’s key chain. Renew the registration for
the 2021 14 passenger van. Place insurance and accident
packet in each vehicle.

excerpt:
(3)&(7)(e) Medications have a prescription
and are stored in the original container with
prescription label Medication Administration Records (MARs) reviewed at
Rising Light and River Rock reflected several times where
missed medication was not appropriately documented.
CORRECTIVE ACTION: Determine if the missed
documentation is related to a specific staff member and
follow up with additional training. Remind all staff the
importance of medication documentation.

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

excerpt: (3)(d) Annual performance evaluations

excerpt:
(a) Agency policies and procedures New Employee Orientation for three staff members could not
be verified during the audit of personnel files.
CORRECTIVE ACTION: Submit a plan as to how new
employee training will be provided and appropriately
documented from this point forward.

excerpt: (b) Ethical and professional guidelines

excerpt: (c) Organizational lines of authority

excerpt: (d) Attributes of population served

excerpt:
(e) & (5)(a) to (c) Mandatory reporting that
includes:
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter 106,
section 36
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee

excerpt: (f) Privacy laws

excerpt: (g) Emergency procedures

excerpt:
Employees who handle
food served to children have a valid food
handler’s card Four out of five personnel files did not reflect the completion
of required ongoing training in these areas.
CORRECTIVE ACTION: Submit a plan as to how this
training will be provided and appropriately documented from
this point forward.
The program’s counselors are the designated staff members
trained in the application of prudent parent standard.

excerpt:
Employees transporting
children have: current driver’s license,
insurance, trained in emergency procedures
and behavior management, and training for
15+ passenger vans if applicable)

excerpt:
Environmental
emergencies

excerpt: Universal Precautions

excerpt:
Discipline and Behavior
Management

excerpt:
Mandatory reporting
(annually) that includes:
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter 106,
section 36
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee Youth files reviewed do not reflect the documentation of age-
appropriate instruction.
CORRECTIVE ACTION: Develop a procedure where age-
appropriate instruction is documented in the youths’ files
from this point forward.

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

excerpt: (f) Impose a dress code

excerpt:
(g) Apply the reasonable and prudent parent
standard

excerpt:
(a) Information regarding personal or room
searches and protocols for confiscation of
contraband Disclosure regarding personal and room searches and
protocols for confiscation of contraband could not be located
in the youth files.
CORRECTIVE ACTION: Add required disclosure to intake
packet. See rule for reference: 413-215-0576 Consents,
Disclosures, and Authorizations
(Amended 09/01/2021) (2) Disclosures to parent or legal
guardian. At the time a residential care agency takes a child
in care into placement, the residential care agency must
ensure that each parent or legal guardian of the child in care
receives and acknowledges in writing the receipt of each of
the following: (a) Information regarding any personal or room
searches and protocols for confiscation of contraband items,
including the notification of law enforcement if illegal
contraband is discovered. This information will include the
procedures and rationales of the residential care agency for
any program-initiated room or body search.
Disclosure stating that policies and procedures will be
provided upon request.

excerpt:
(c) Any policies and procedures upon
request

excerpt:
(a) Disclose or exchange information with
others Two out the five youth files reviewed did not have activity
specific authorizations.
CORRECTIVE ACTION: Ensure that this authorization is
obtained and kept in the respective youth file from this point
forward.

excerpt:
(d) Activity specific authorizations are pre-
approved to allow children to participate in
potentially hazardous activities, including but
not limited to using motorized yard
equipment, swimming, and horseback riding.