summary: License Renewals - 8 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Licensee: Morrison Family Services Date of site visit: November 14-16, 2022
Executive Director: Drew Henrie-McWilliams Licensing Coordinator: Jorge Pelinski, Holly Ivey, Tom Heidt, Ed
Wyller and Irvin Minten
Program Compliance: The program is or will be compliant with OAR 413-215-0001 through 0131 Licensing Umbrella Rules, OAR 413-215-0301
through 0396 Licensing Foster Care Agencies, OAR 413-215-0501 through 0586 Licensing Residential Care and OAR 413-215-0801 through 0856
Licensing Day Treatment.
Personnel records were reviewed and compliance with required background checks was documented for employees in all programs.
Agency Description(s) as provided by Morrison:
Morrison Child and Family Services was founded in 1947, by Carl V. Morrison, who was a psychologist in Portland. It has grown to be a large
organization with a projected annual budget of around 33 million, and they employ approximately 414 employees. Morrison Child and Family
Services served 10,996 children in and families in 2021-2022. Morrison has programs that are licensed by Oregon Department of Human Services
(ODHS) Licensing and outpatient programs that are not.
Individual Program Description(s):
Planned and Crisis Respite Care (PCRC)- Provides planned or emergency short-term overnight respite services for children 3-17 years old.
Respite providers are certified Therapeutic Foster Parents through Morrison. The providers have been screened and specially trained to work with
children and youth who have a history of mental illness and may have been impacted by trauma. Respite homes provide a safe, supportive and
structured environment in which youth can take advantage of new opportunities. The average length of stay in 2020 was 2 days and the service is
primarily utilized on weekends.
Therapeutic Foster Care-
Morrison’s Therapeutic Foster Care (TFC) program provides a safe and nurturing environment with care provided by specially screened parents
who are trained to work with children and youth impacted by trauma. TFC children and youth are 3-17 years old living in the Portland-Metropolitan
area and have been referred by their Child Welfare Caseworker for Therapeutic Foster Care because of clinical and behavioral issues that require
specialized care. Morrison’s TFC program is contracted to provide care for up to 12 children. Often youth participating in TFC have experienced
multiple attachment disruptions and have suffered neglect as well as severe physical, sexual and emotional trauma. As a result, they can
experience mental health and behavioral issues that make it difficult for them to cope with daily routines and relationships. The average length of
stay in 2021 was 448 days. At the Licensing Review it was reported there were 5 certified foster homes, with a capacity of to serve 6 children.
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 170823)
Counterpoint Day Treatment -This program was founded in 1983. The Counterpoint Day Treatment and Proctor Care Program is a
comprehensive program that combines mental health and sexual offending treatment approaches with an accredited school program and proctor
care. The day program is open 8:45 am to 4:00 p.m. Monday-Friday and serves adolescent boys 12 to 17 years old that have sexual behavior
difficulties. Proctor homes provide care, support and supervision evenings and weekends for youth in OYA custody. Youth can be referred through
various sources: families, DHS, school, although most are referred by the Oregon Youth Authority Staff. Treatment services occur throughout the
day and include peer group meetings, offender accountability groups, abuse survivor/personal history groups, alcohol and drug education groups,
alcohol and drug treatment groups and behavioral skills groups. Group skills training also includes sex education, anger management,
assertiveness training and healthy relationships. Youth have access to individual and family counseling, medical care, case management and
psychiatric services. A full range of adolescent substance use treatment and recovery services are provided when needed. This program focuses
on teaching positive, age-appropriate social skills while helping clients to resolve personal issues and cope with earlier trauma. Research indicates
that early intervention with adolescents can eliminate future sexual offenses as well as significantly decrease the likelihood of social, emotional and
developmental problems from developing later in their lives. The school day is provided by Portland Public School teaching staff. Cognitive-
behavioral treatment strategies and interventions are used throughout the program.
Counterpoint Foster Care – Youth live in proctor care homes specifically recruited and supported by Morrison to provide a therapeutic home
environment. Proctor parents are certified through the Oregon Youth Authority. Proctor parents receive training, supervision, and support by
Morrison Staff. Proctor parents are highly involved in care planning and receive information daily from day treatment staff about youth progress and
behavior. Counterpoint staff provide monthly home visits and home inspections to provide feedback and support for proctor parents. Proctor
parents also receive individualized coaching when they request additional support, when youth needs increase or change significantly and when
staff assess that increased supervision would be beneficial. For safety and therapeutic reasons, no young children are placed in these homes. At
the Licensing Review it was reported there were 5 certified homes with a capacity to serve 14 children. The average length of stay for youth in care
during 2022 was 457 days.
Downtown Shelter – The Downtown Shelter is a 50-bed youth shelter located in downtown Portland that serves immigrant youth, 13-17 years old.
Both males and females are served but housed in separate areas of the facility. The Program opened July 2014. It provides temporary housing in
a supervised living environment, 6 hours of education per day and case management services designed to support the re-unification process.
Referrals are made to community resources for outpatient medical, dental and mental health services. Supportive counseling services are also
provided by Downtown Shelter clinicians when needed. The primary goal of the Program is for children to be placed with family members or an
identified sponsor. Services are designed to achieve this goal. The Downtown Shelter program provides residential services in partnership with the
US Department of Health and Human Services, Administration for Children and Families, Office of Refugee and Resettlement (ORR). All services
are planned and coordinated with ORR Federal Field Specialists acting as legal guardians. Youth are referred to the Shelter based upon an
assessment of their developmental and behavioral needs that indicates that they can function safely and successfully in an open, less restrictive
2
environment. Individual service needs and level of care is reviewed frequently (every 30 days) with the ORR Federal Field Specialist. In this model
influenced by child welfare practices, Morrison does not make initial placement, transfer or discharge decisions but acts as a care provider and
advocate for the youth. The population served is primarily immigrant youth from Central and South America who have entered the United States
without parents or legal guardians and without a legal immigration status. The youth typically speak Spanish or indigenous languages spoken in
their home countries. The average length of stay in 2022 was 30 days.
Long Term Group Home-The Long-Term Group Home is a residential program serving immigrant youth, 13-17 years old. It is co-located with the
Morrison Downtown Shelter Program but has separate physical space and staffing. The Program opened in April 2017. The Long-Term Group
Home program provides residential care, health care follow-up, socialization/recreation, life skills training and development, access to legal
services, case management services and mental health counseling, if needed. Youth placed in the program attend Lincoln High School during the
day and return to the Program after school and extra-curricular activities are completed. All services are coordinated closely with ORR Federal
Field Specialists who act as legal guardians. In this model influenced by child welfare practices, Morrison does not make placement or discharge
decisions, but acts as a care provider and advocate for youth served. Immigrant youth served within the Long-term Group Home program do not
typically have serious behavioral or developmental concerns. They require a long-term placement, usually 6-9 months, because there is not an
identified family member or adult sponsor to act as a legal guardian in the US. Consequently, programmatic and system goals are to assist youth in
understanding and adjusting to their legal status and prepare for independent living. Family or sponsor re-unification remains a goal if it is possible
to achieve. Services provided are community-based, supportive, and “as-needed”. Youth attend a public high school and participate in extra-
curricular high school activities without direct, face-to-face supervision from program staff. They receive less frequent case management services
and utilization of supportive counseling services is not required. Additional criteria for placement within the Long-term Group Home include: being
under the age of 17.5 years at the time of placement and potential eligibility for “immigration” or “legal” relief. The population served are primarily
youth from Central or South America who speak Spanish and indigenous languages spoken in their home countries. They have entered the United
States without a parent or legal guardian and without legal immigration status. The average length of stay in 2022 was 149 days
SAGE Residential – The Support, Achieve, Grow, and Empower (SAGE) Program serves Commercially Sexually Exploited Children (CSEC) who
have been identified as needing intensive services to prevent future victimization. The secure residential setting allows staff to build a relationship
with each youth while engaging them in services. The foundation of the CSEC program is the Sanctuary Model, and the milieu utilizes Collaborative
Problem Solving. SAGE serves female identifying youth, ages 11 to 16.5, who are residents of the state of Oregon and have experienced
commercial sexual exploitation. The program is designed to last 11 to 14 months. It includes a full range of mental health treatment (individual,
group, family, psychiatric), substance abuse treatment, milieu therapy, on site education, medical case management services and education and
treatment specific to commercial sexual exploitation and sex trafficking. Portland Public Schools provides an on-site school. Their contract with
Oregon Health Authority is for 12 youth, ages 11-16.5, but the program has the capacity to serve 26 youth ages 10-17. The average length of stay
in 2022 was 231 days.
Program type and services: Residential, Foster Care, and Day Treatment Services
Number of proctor foster parents and program capacity: The number of proctor foster parents and program capacity was identified by program
managers.
3
Planned Crisis Respite Foster Care: 12 certified foster homes, capacity 21
Foster Care Program: 5 certified foster homes, capacity- 6
Counterpoint: 5 certified foster homes, capacity- 14
Average length of stay: The average length of stay was identified by program managers.
Planned Crisis Respite Foster Care: (Primarily this service is only utilized on weekends)
 2021- 2-3 days
 2022- 2-3 days
Foster Care Program:
 2021- 448 days
 2022- 268 days
Counterpoint:
 2021- 321 days
 2022- 457 days
SAGE:
 2021 315 days
 2022 231 days
Residential Care Program Update-Long Term Group Home:
 2021- 95 days
 2022- 149 days
Residential Care Program Update-Shelter:
 2021- 33 days
 2022- 30 days
Average daily population served: The average daily population was identified by program managers.
Planned Crisis Respite Foster Care:
 2021- 62 children
 2022- 50 children
Foster Care Program:
 2021-5 children
 2022- 4 children
Counterpoint:
4
 2021-8 children
 2022- 22 children
SAGE:
 2021-16 children
 2022- 14 children
Residential Care Program Update-Long Term Group Home:
 2021-11 children
 2022-18 children
Residential Care Program Update-Shelter:
 2021-9 children
 2022- 12 children
Number of children served annually: Number of children served was identified by program managers.
Planned Crisis Respite Foster Care:
 2021- 93 children
 2022-82 children
Foster Care Program:
 2021-11 children
 2022-6 children
Counterpoint:
 2021- 16 children
 2022- 18 children
SAGE:
 2021-33 children
 2022- 33 children
Residential Care Program Update-Long Term Group Home:
 2021-10 children
 2022- 22 children
Residential Care Program Update-Shelter:
 2021- 101 children
 2022-155 children
Use of seclusion or restraint: Morrison programs prohibit seclusion. Staff at the following programs are trained in Non-violent Crisis Intervention
(NCI) as restraints are allowed in emergency situations: The Downtown Long-Term Group Home and Shelter. SAGE Staff are trained in the Mandt
5
Intervention System. Counterpoint Day Treatment, and Morrison Foster Care are “hands off” programs. The staff are trained in NCI’s non-physical
interventions and de-escalation techniques.
Interviews, Observations:
Interviews: At the Licensing Review fifteen staff members, two foster parents and six children were interviewed. The following information was
gained during the interviews with the children:
 Many children reported appreciating the staff. Some children preferred some staff over other staff.
 The children all reported being able to talk to people on their approved contact list.
 The Sage youth interviewed desired more outdoor time, stating they aren’t able to go outside every day. The Licensing Coordinator spoke
to the Program Manager, Kelli Doolittle, and Program Supervisor, Allison Jacoby-Fries, who stated the youth are offered outdoor time daily
but sometimes the youth choose not to go out because of other activities they are doing inside at the time they are offered. Sometimes
youth will ask to go outside at other times, and staff are not always available to take them outside at the requested time.
 All the children reported being provided enough food to eat, to include receiving daily snacks. Some reported wanting more variety with food
options. One youth at the Downtown Shelter Program reported having dental challenges that limited her from eating certain foods (hard
textured) She expressed wanting more options of softer foods to eat. The Licensing Coordinators followed up with the Program Manager
who stated she would follow up with the nutritionist. Prior to the interview there had been follow up by the program’s medical staff regarding
this issue.
 The children all reported their hygiene needs were being met by the program.
 All the children but two reported feeling safe at the programs where they were residing, to include foster homes. Two Sage Youth reported
not feeling safe in the program, when asked why they didn’t feel safe they stated:
o “Most of the time I feel safe, I have heard from other youth about other clients going into bedrooms while someone is asleep.” (This
has not been this person’s experience, and she stated she has expressed these concerns with staff.) It is a program rule that
bedroom doors cannot be locked when youth are in their bedrooms.
o “I do not feel safe here, and I have told staff how I feel. People hit each other a lot, three girls left this month for hitting another youth
and one youth hit a staff.” She also shared that a youth had chocked a staff. She shared a youth was in a rolling chair and was
asked by staff to get out of the chair. The youth refused to move, and the staff pulled the youth by her ponytail into another room and
dumped the youth out of the chair. This was called into the Child Abuse Hotline on November 15, 2022, by the Licensing
Coordinator. Prior to leaving the Sage Program, the Licensing Coordinators, spoke with the Program Director, Kelli Doolittle
regarding this concern.
Observations: While conducting the onsite inspection at the programs, children and staff were observed. The children that were observed appeared
to be at ease and comfortable while residing in the programs. The facilities were observed to be well maintained, with minimal repair needs as
stated below in the report.
Agency Strengths:
The following strengths were identified by Morrison Leadership:
6
 “The agency has increased wages for their employees.
 The staff, the team, and leaders want to expand their programs, and are committed to their jobs.
 Youth feeling that the staff care about them.
 Longevity of Leadership.
 The agency has a commitment to quality of care.
 March 2022, is the 75th Anniversary for Morrison Family Services.”
Individual Program Strengths: Identified by program managers.
 Foster Care Program (to include Planned Respite Care):
o “TFC & Behavior Health (BH)-TFC & PCRC: The youth, though a small number, were supported and maintained in their placements
throughout the Pandemic. Resource parent supports also continued with many services provided remotely. When school resumed,
resource parent responsibilities for schooling and educational supports was eased. While the Program experienced some staff turnover,
new Foster Care staff were hired and oriented to the Program. The Program received Workforce Stabilization Grant funds to help bolster
staff shortages and support the recruitment and retention of resource homes. The Behavioral Health Therapeutic Foster Care pilot
project was initiated to integrate Behavior Rehabilitation Services (BRS) therapeutic foster care services with intensive mental health
treatment. BH-TFC is a state-wide project in which Morrison is one of seven agencies providing this new service. A community-based
mental health therapist was hired to support the mental health needs of BH-TFC and TFC youth. The program also added a new
position, a Business Manager, to support the foster care programs with budget plans, donation support and tracking, and grant reporting.
During this time, the respite program maintained its utilization of respite beds. Since COVID-19 restrictions have lifted, more respite
placements have occurred.”
 Counterpoint:
o “Counterpoint Day Treatment and Proctor Care (CPDT) programs have a long history of successful treatment outcomes. The length
of service for CPDT proctor parents is longer than average due to training, peer supports, frequent respite, and daily support of the
day treatment program staff. CPDT management staff are long term Morrison employees. The Program has had a recent increase in
referrals from ODHS and local school districts for day treatment services only. Flexible service opportunities are offered, such as
serving a ODHS referred youth in day treatment and placing the youth in an OYA certified proctor home. The Program also has the
opportunity to add outpatient sexual offense treatment services within the existing OYA contract. There is also an Outpatient
Substance Use Disorder (SUD) Treatment Services component within CPDT and CPDT has qualified Certified Drug and Alcohol
Counselor (CADC) staff. Counterpoint Day Treatment continued services throughout the Pandemic despite stay-at-home orders and
the need for intensive infection control protocols. Youth were transported to the Center daily and a school day was provided
remotely. BRS services and treatment services continued in person or remotely.”
 SAGE:
o “SAGE has a very strong foundation of trauma informed care that guides all treatment and interpersonal activities at SAGE.
7
o SAGE is fortunate to have adequate and sustainable funding from OHA. This funding allows us the ability to provide a safe, comfortable,
welcoming, and therapeutic environment for youth. Recent rate increases have helped with providing competitive salaries.
o Leadership positions at SAGE have very low turnover which contributes significantly to program stability and quality
o Morrison has invested in Joint Commission Accreditation and is pursuing Sanctuary Certification which both add an additional layer of
quality to the program.
o The ability to provide long-term treatment allows us to really form relationships with the youth, provide high quality mental health and
substance use treatment, and increases their chance of a successful discharge.”
 Residential Care Program Update-Long Term Group Home (LGTH), and Downtown Shelter Program (ORR):
o ‘“The Downtown Shelter and Long-Term Group Home youth reported overall satisfaction with the program and that they received
support from the program during their stay.
o Increased training for supervisors on relationship building and importance of supervision. Providing additional training for all
supervisors to support them in setting expectations, clarifying roles, and agency requirements. This is being done to increase staff
retention and satisfaction.
o Programs are continuing to provide the Child and Youth Care Certification Board training to all direct care staff. Currently most of the
direct care staff have gone through the training and certification process.
o Staff have been cross-trained in different areas and programs, allowing for back-up coverage and consistent program operations
when there is a fast-paced work environment and staff turnover. Staff have successfully supported multiple programs.
o Programs have created a welcoming environment for youth by integrating more cultural appropriated resources in their education,
recreational activities, food, communities’ groups, and mental health resources. Recreational spaces for youth such as our second-
floor gym, activity and peace room have allowed youth to find a safe and healthy method for releasing frustrations. Youth have
benefited from recreational activities such as Soccer coaching, Educational outings, Gardening classes, Art & Music classes, and
talent shows.
o Programs adapted to the challenges of the COVID-19 Pandemic with flexibility and creative approaches; implemented and followed
multiple infection control procedures.”
Program Challenges: Individual challenges identified by program managers.
 Foster Care Program (to include Planned Respite Care):
o “Significant program challenges were related to the impact of COVID-19. Youth were schooled at home placing additional
responsibility on foster parents. Foster home recruitment slowed down significantly due to COVID-19 restrictions slowing program
growth and development. Morrison’s BH-TFC pilot started in May 2021 and a community-based mental health therapist was added to
the foster care team. Unfortunately, the therapist resigned after 6 months and rehiring for the position took nearly 9 months. Youth
were transferred to the Morrison Outpatient Community-Based Program during the interim for continuity of care and treatment.
Resource parents also decided to close their homes and discontinue their foster care certifications, some due to COVID-19 and
others due to life changes within their families and households. The reduction of resource homes and the current challenges of
recruiting new homes remains difficult.”
 Counterpoint:
8
o “Recruitment of proctor parents who are qualified to serve this high-needs population is difficult. Open staffing positions are also
increasingly difficult to fill due to fewer people looking for work and the need for professional staff in highly specialized fields i.e.
addictions treatment and sexual offense treatment. At the present time OYA proctor home beds are unfilled. Another challenge is the
cost of required staff training. Training often requires supplemental staffing to cover day treatment programming while the on-going
staff are in training. Facilities upkeep takes longer due to the lack of contractors or the lack of availability. Improvements needed can
be prohibitive due to increasing building costs and lack of budget availability. Vandalism or theft of agency vehicles have caused
increased spending on repairs and increased attention to security concerns. Lack of diverse service providers limits client
populations that can be referred. At the present time the CPDT staff are English-speaking only. Meal services are dependent upon
the availability of school district dining services and their capacity to deliver daily food. The need to purchase food for clients during
times when school is not in session has increased and the lack of cooking facilities onsite limits options.”
 SAGE:
o “Staffing has been a challenge due to COVID and SAGE funding. SAGE was not eligible for several residential rate increases that
were given to BRS programs and other mental health residential programs. Other community programs increased salaries and
SAGE was unable to increase salaries until very recently.
o High acuity youth with frequent escalations led to milieu instability, staff injuries, and property destruction on a few occasions.
o Many recent referrals are youth with significant histories of aggression. SB 710, increased investigations, and the impact on staff
involved in highly aggressive incidents has influenced our willingness to take these youth.”
 Residential Care Program Update-Long Term Group Home and Downtown Shelter Program (ORR):
o “Throughout the past two years Morrison has continued to experience significant challenges and delays in hiring staff for
the Downtown Shelter and LTGH programs. Challenges have occurred in the following areas: recruiting and hiring direct
service and management staff with the qualifications necessary for the vacant positions.
o Staff resignations and staff turnover have put pressure on service delivery and program operations.
o The COVID-19 pandemic impacted the programs as more staff were out sick for longer periods of time and programs
were required to manage housing youth in isolation and quarantine floors. Working in residential settings became less
desirable.
o Programs received a new population of youth that they were not quite prepared to receive due to language barriers and
behavioral challenges.
o Higher acuity youth with behavioral and mental health challenges.
o Programs were not at capacity due to staff shortages.”
Changes that have occurred in the last 2 years: Individual program changes in the last two years identified by program managers.
 Foster Care Program (to include Planned Respite Care):
9
o “Significant programmatic changes occurred in response to COVID-19 precautions and protocols altering the way that the Program
interacted with youth, resource parents, and the community. Masking and social distancing continued and working from home
became the norm. The program offered both telehealth services, virtual home visits, and in-person contacts. Foster youth contact
was maintained throughout the Pandemic. In May 2021, the Morrison Foster Care Program began piloting the BH-TFC program and
hired a community base mental health therapist to support the intensive mental health needs of youth. In September, 2021 Morrison
foster care programs made the policy decision to prohibit physical restraint of foster children. Program managers have been
responding to new SB 710 reporting.”
 Counterpoint:
o “Counterpoint expanded its program space after the closure of Breakthrough Day Treatment on June 30, 2022. The addition of 2
proctor homes has also increased the available beds for day treatment and proctor service from 9 to 14 youth. ODHS and local
school district day contracts for day treatment only services have become more common and frequent. Counterpoint Outpatient
closed last year and the Counterpoint Day Treatment Program has accepted referrals for outpatient services, too. OYA is contracting
with Morrison to provide these services. The Rotary Youth Center was completed and was extremely beneficial for the youth through
the pandemic when there were few options for public activities. Because of the continuous vandalism and theft of the day treatment
vehicles, they are now parked offsite at the Mt Scott residential location. It is an inconvenience to store and retrieve vehicles off-site,
but there are fewer security issues. A new minivan was purchased during the new car shortage. This vehicle replaces the usage of
1 of our 12 passenger vans and allows us to transport small groups of youth in a more reasonably sized vehicle.”
 SAGE:
o “Implementation of new programming assuring that youth have more consistent and more private contact with family and supports.
o Implementation of staff training, new program policy, and client education and support regarding racial and cultural diversity.
o Expanded courtyard garden area, partnered with Portland Public Schools to develop an integrated earth science program for youth in
care.”
 Residential Care Program Update-Long Term Group Home and Downtown Shelter Program:
o “New Division Director started in May 2021.
o Shelter and Long-Term Group Home have not been at capacity for the past two years.
o DT Shelter Program started accepting female youth again in June 2022.
o New positions were created to bring full focus and attention to hiring and supporting the Milieu components of the programs.”
Lawsuits: There were no lawsuits reported by Morrison Leadership to Licensing since the last Licensing Renewal.
10
Grievances and complaints filed in the last two years: None in the past two years were reported.
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report Morrison Family Services, must submit a letter of verification indicating the agency is in compliance with the
specific rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency must
submit any and all specific documentation requested in the body of this report. The letter of verification and any additional requested documents can
be emailed directly to Jorge Pelinski at: Jorge.l.pelinski@dhsoha.state.or.us
Recommendations: None
Exceptions: N/A
Changes in License: None
Summary of Review
Program and Services Corrective Action
Yes No N/A Corrective Actions
413-215-0011(2) Completed
Program and services are in scope of license X
Governance of the Agency Corrective Action
Yes No N/A Corrective Actions
413-215-0021 Completed
(1)(a) Minimum of 5 board members X
(2)(f) Formally evaluate the exec. Director’s X
performance annually
(2)(g) Approves annual budget X
(2)(h) Obtain and review an annual X
independent financial review or audit of
financial records.
11
(2)(k) Written quality improvement program X
(2)(l) Meeting minutes X
Executive Director or Program Director Corrective Action
Yes No N/A Corrective Actions
413-215-0021 Completed
(3)(a) knowledge of requirements for X Executive Director or Program Director 413-215-
providing care and treatment appropriate to 0021(3)(g) Approval from BCU
programs  Kelli Doolittle, Sage Program Director’s Background
(3)(g) Approval from BCU X Check was submitted by Morrison to the ODHS
Background Check Unit (BCU) at the time of the
review. The fitness determination was in process at
the time of the review.
Discipline, Behavior Management, and Corrective Action
Yes No N/A Corrective Actions
Suicide Prevention 413-215-0076 Completed
(3) Agency uses appropriate and positive
methods of behavior management and
nationally recognized non-violent crisis X
intervention The agency utilizes NCI, and
Mandt.
(3)(b)(C) Agency does not use chemical and
mechanical restraint (excluding medically
X
necessary devices/prescriptions)
(3)(c) Agency uses appropriate time-out
rooms (adequate space, heat, light and
ventilation and is not capable of locking) and X
documents use in child’s record when
applicable
(3)(e) Agency uses seclusion
X
appropriately/consistent with policy
(4) Agency has adequate plan in place to
respond to suicidal behavior/warning signs X
Contractors (if applicable) Corrective Action
Yes No N/A Corrective Actions
413-215-0061(6) Completed
(a) Agency ensures the contractor meets the
requirements of this rule and Chapter 413 X
division 215
12
(b)(B) Contract includes the following:
(i) Services provided
(ii) Contractor fees
(iii) Disclosure of information from contractor
to agency
(iv) Lines of authority X
(v) Adherence to rules, including background
check
(vi) Any liability of the agency for acts of the
contractor, rights of indemnity and limitations
on liability
Supplemental Information Provided by Yes No N/A Corrective Actions Corrective Action
CCA Completed
Documents as indicated on the form titled Supplemental Information Provided by CCA Documents
“Renewal Licensing Required Documents” as indicated on the form titled “Renewal Licensing Required
Documents”
 Certificates of Occupancy: Sage, and the
Downtown Building.
X  Fire Marshal Inspections for all sites were
completed, violations were found at all sites. The
agency must submit verification that the
violations have been remedied.
 Environmental Inspections for all sites.
Documents as indicated on form titled
“Required Financial Documents and X
Information”
All required policies and procedures as Supplemental Information Provided by CCA All required
identified in the “Umbrella Rules” policies and procedures as identified in the “Umbrella Rules”
X
 *See page 43 for details of Umbrella Policy
Revision requirements
All required policies and procedures as Supplemental Information Provided by CCA All required
identified in “Agency Type Specific Rules” policies and procedures as identified in “Agency Type
Specific Rules”
X
 *See page 43 for details of Agency Type Policy
Revision requirements.
13
Sage, Long Term Group Home (LTGH), Downtown Shelter Program
(ORR) Residential License
Physical Plant Corrective Action
Yes No N/A Corrective Actions
Completed
413-215-0046(3)(a) Foster Rights Posted (if X
children in DHS custody) Physical Plant 413-215-0511(2)(a) &(c) Buildings are
413-215-0051(1) Sufficient safe space, X smoke free, clean and in good repair
equipment, and office equipment The following was identified in need of repair:
413-215-0091(12) License is posted in X Downtown ORR Shelter:
common area at each facility o (LTGH) 4th Floor touch up paint needed in small
413-215-0001(5)(d), 0516(4(a)(I) & 0521(1) X areas in the hallway.
Adequate furnishings and personal items o (LTGH) Bedroom 40A Two holes needed to be filled
413-215-0511(2)(a) &(c) Buildings are X and paint needed,
smoke free, clean and in good repair
413-215-0511(2)(d) Rooms are free of X
harmful drafts, odors, and excessive noise
413-215-0511(2)(e) Rooms are adequate in X
size and arrangement
413-215-0511(2)(f) System provides a X
continuous supply of hot and cold water to
taps located throughout the facility
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
ensure the safety of children
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions
Bedrooms 413-215-0516(3) Completed
(a) Adequate furnishings and personal items X Room and Space Requirements Bedrooms 413-215-
(b) Separate from rooms used for dining, X 0516(3) (c) Outside room with window allowing egress
living, laundry, kitchen, and storage from building
(c) Outside room with window allowing X
egress from building  Sage, LTGH, and the ORR residential programs,
(d) Ceiling at least 90 inches X windows do not allow egress.
(e) Minimum 60 SF per bed X
(f) No more than 25 if dorm style X
(g) Permanently wired fixtures X
(h) Window covering X
(i) Beds are 3 feet apart and maintained to X
ensure safety
14
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions
Bathrooms 413-215-0516(4) Completed
(a)(A)&(B) 1:8 ratio for toilets and sinks X
(a)(D) Hot and cold running water, soap, and X
approved hand drying options
(a)(E) 1:10 ratio for shower or bathtub X
(a)(E) Individual privacy X
(a)(F) Window covering X
(a)(G) Permanently wired fixtures X
(a)(H) Adequate ventilation X
(b)&(c) Wooden racks on floors are X
prohibited and impervious shower mats are
disinfected & dried daily
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions
Kitchen 413-215-0516(6) Completed
(a) Used exclusively for storage, food X
preparation, dish washing, and activities
related to eating
(b) Walls, floors are easily cleanable X
(c) Equipment and utensils are easily X
cleanable, durable, nontoxic, and kept clean
(e) Equipment is easy to clean beneath, X
between and behind
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions
413-215-0516 Completed
(2) There is a separate living room or lounge X
area – 15 SF minimum per child
(5) There is a separate dining room with X
capacity for ½ of children in care and 15 SF
per child in care
(7) Laundry is separate from living areas, X
kitchen and dining
(8) Separate storage areas are provided for X
food, kitchen supplies, utensils, clean linens,
soiled linens and clothing, cleaning supplies
and equip, poisons, chemicals, outdoor
recreational and maintenance equipment
(9) Outdoor activity area is protected from X
vehicles and other hazards and of a size and
availability appropriate to the age and needs
of children in care
(11) & 413-215-0076(3)(c)(C) Time out X
rooms have adequate space, heat, light and
ventilation and is not capable of locking
15
Furnishings and Personal Items Corrective Action
Yes No N/A Corrective Actions
413-215-0521 Completed
(1) There is a bed with frame, clean mattress X
and pillow and personal storage (dresser,
closet)
(2) Linens are in good repair. There is a X
waterproof mattress cover or mattress.
Linens are appropriate and towels and
washcloths are provided
(3) Bedding is changed weekly or when X
soiled
(4) & (5) Personal hygiene supplies and X
appropriate clothing are provided
Food Services Corrective Action
Yes No N/A Corrective Actions
413-215-0536(1)&(2) Completed
(1)(a) Meals are arranged daily, consistent X
with normal mealtimes that occur during the
hours of operation
(1)(b) Menus are prepared in advance in X
accordance with USDA guidelines, provide a
variety of foods and are adjusted for
seasonal changes.
(1)(b) Menus are kept for at least 6 months X
(1)(c) Drinking water is freely available X
(2)(a) Food is stored, prepared & served in a X
sanitary manner
(2)(c) & (d) Food products are obtained from X
commercial suppliers (exception of fruits &
vegetables), unpasteurized juice is
prohibited, and only Grade A pasteurized
and fortified milk in appropriate container.
Safety Corrective Action
Yes No N/A Corrective Actions
413-215-0541 Completed
(2)(a) Written emergency plan X
(2)(b) Telephone numbers for local police X
and fire are posted near all telephones
(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
16
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
Safety – Transportation Corrective Action
Yes No N/A Corrective Actions
413-215-0541 Completed
(5)(b) Vehicle has insurance policy, is smoke X
free, safe operating condition, and has first
aid kit and fire extinguisher 2-A:10-BC
Medication Corrective Action
Yes No N/A Corrective Actions
413-215-0551 Completed
(3)&(7)(e) Medications have a prescription X
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
medications is maintained and includes:
(a) description and amount
(b) name
(c) reason
(d) method
(e) staff & witness signature
(10) Written record of the administration X
of medication includes:
(a) name
(b) description
(c) dates and times
(d) missed doses
(e) medication disposed
(f) method of administration
(g) ID of person administering
(h) possible adverse reactions
(i) medication taken outside facility
Extracurricular, Enrichment, Cultural &
Corrective Action
Social Activities Yes No N/A Corrective Actions
Completed
413-215-0554
17
(2) Children have ongoing opportunities to X
participate in at least one age-appropriate or
developmentally appropriate activity
Minimum Staffing Requirements Corrective Action
Yes No N/A Corrective Actions
413-215-0561 Completed
(1) &(2) Supervision is adequate for the type X
of program, location, age and type of
children, ability of supervisor to respond,
electronic back-up systems.
Minimum ratios are maintained:
Under 30 months of age: 1:4
30 months to ˃ 6 yrs. or non-ambulatory: 1:6
Ages 6 and older: 1:7
Overnight (staff awake)
1:10
(4)(a) When one staff on duty, there is X
additional staff immediately available with
max response time of 30 minutes
(5) There is at least one on-site employee X
authorized to apply the reasonable and
prudent parent standard
Separation of Residents Corrective Action
Yes No N/A Corrective Actions
413-215-0566 Completed
(1) Children are in separate bedrooms than X
adults, unless parent and child, or there is
written approval from guardian/parent and
licensing coordinator
(2) There is adequate supervision of children X
if both males and females are served by the
program
Personnel Files Corrective Action
Yes No N/A Corrective Actions
413-215-0061 Completed
Staff Name/Position X
(3)(g) Date of Hire X
(3)(a) record of education, training and X
previous employment
18
(1)(b) & (3)(b) reference checks completed X
and documented Personnel Files 413-215-0061(1)(a) & (3)(c) Background
check completed and documented
(1)(a) & (3)(c) Background check completed
and documented X  One Background Check was not found in the
personnel files reviewed for a Sage Staff.
(3)(d) Annual performance evaluations X
 Two Background Checks were not found in the
(3)(f) Record of personnel actions X personnel files reviewed for the ORR Program.
(3)(g) Termination date, reason for X
termination
(3)(h) Current job description (1)(c) X
Employee meets minimum qualifications
stated in current job description
New Employee Orientation – Umbrella
Corrective Action
Requirements (30 days) Yes No N/A Corrective Actions
Completed
413-215-0061(4)
(a) Agency policies and procedures X
(b) Ethical and professional guidelines X
(c) Organizational lines of authority X
(d) Attributes of population served X
(e) & (5)(a) to (c) Mandatory reporting that X
includes:
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter 106,
section 36
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
(f) Privacy laws X
(g) Emergency procedures X
New Employee Orientation – Residential
Corrective Action
(30 days) Yes No N/A Corrective Actions
Completed
413-215-0556
(1)(a) Discipline and behavior management X
including de-escalation, crisis prevention,
positive behavior management, and
disciplinary techniques that are non-punitive
in nature
(1)(b) Restraint and seclusion (if applicable) X
Ongoing Training Corrective Action
Yes No N/A Corrective Actions
Completed
19
413-215-0536(2)(b) Employees who handle X
food served to children have a valid food
handler’s card
413-215-0541(5)(a) Employees transporting X
children have: current driver’s license,
insurance, trained in emergency procedures
and behavior management, and training for
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 X
must maintain current CPR/First Aid
certification
413-215-0556(4) Designated staff authorized X
to apply reasonable and prudent parent
standard are trained in application of the
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
Contractors (if applicable) Corrective Action
Yes No N/A Corrective Actions
413-215-0061(6) Completed
(a) Agency ensures the contractor meets the
requirements of this rule and Chapter 413 X
division 215
(b)(B) Contract includes the following:
(i) Services provided
(ii) Contractor fees
(iii) Disclosure of information from contractor
X
to agency
(iv) Lines of authority
(v) Adherence to rules, including background
check
20
(vi) Any liability of the agency for acts of the
contractor, rights of indemnity and limitations
on liability
Children’s Records Corrective Action
Yes No N/A Corrective Actions
Completed
Name X
Health Services
413-215-0546
(2) Medical history obtained within 30 days X
(significant findings, current immunizations,
history of surgical procedures-health issues-
injuries, allergies, dental, vision, hearing,
behavioral health, and physician orders)
(2)(e) Documentation of age appropriate X
instruction – pregnancy prevention, nutrition,
prevention of HIV & AIDS, and prevention
and treatment of sexually transmitted
disease
(4)(a) to (f) Medical exams (3 in first year of X
life, 2,4,6,9,14)
Consents Corrective Action
Yes No N/A Corrective Actions
413-215-0576(1) Completed
(a) Provide routine and emergency medical X
care
(b) Use the discipline and behavior X
management system
(c) Use restraint or seclusion (if applicable). X
Must specify the reasons for the intervention
and how staff are trained and supervised
(d) Restrict contact with persons outside of X
the agency
(e) Allow access as defined in 413-215-0091 X
& 0101
(f) Impose a dress code X
(g) Apply the reasonable and prudent parent
X
standard
Disclosures
Corrective Action
413-215-0576(2) Parent/guardian has Yes No N/A Corrective Actions
Completed
acknowledged in writing:
21
(a) Information regarding personal or room X
searches and protocols for confiscation of
contraband
(b) Statement of Rights of Children and X
Parents/Guardians
(c) Any policies and procedures upon X
request
Authorizations Corrective Action
Yes No N/A Corrective Actions
413-215-0576(3) Completed
(a) Disclose or exchange information with X
others
(b) Child specific visitors X
(c) Visitation resources are pre-approved X
(d) Activity specific authorizations are pre- X
approved to allow children to participate in
potentially hazardous activities, including but
not limited to using motorized yard
equipment, swimming, and horseback riding.
Information about Children in Care
Corrective Action
413-215-0581(1) Summary sheet contains Yes No N/A Corrective Actions
Completed
the following:
(a)The name, gender, date of birth, religious X
preference, and previous address
(b) Name and location of previous and X
current school
(c) Date of admission X
(d) Legal custody X
(e) The name, address, and telephone X
number of:
(A) The child in care's parents.
(B) The child in care's legal guardian, if
different than the parents, and a copy of
the document that provides for his or her
authority over the child in care.
(C) Other persons significant to child
(D) Other professionals to be involved in
service planning (if applicable)
Service Planning Corrective Action
Yes No N/A Corrective Actions
413-215-0581(2) Completed
(b) Intake document is completed the date X
child accepted into care (emergency
placement 48 hours)
22
(d) Assessment is completed within 30 days X
and contains relevant historical info., current
behavioral observations, identified need for
services, and how agency will provide
services
(e) (A)&(B) Service plan within 60 days X
(parent, guardian and child actively
involved). Describes how child’s issues will
be addressed, anticipated outcomes and
reviewed by child and guardian/parent.
(e)(C) &(D) Service plan is reviewed X
quarterly and revised when information
indicates other services should be provided
Case Management Corrective Action
Yes No N/A Corrective Actions
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
413-215-0581(4) Completed
Records contain date, amount, source,
X
purpose, signatures
Personal Possessions Records Corrective Action
Yes No N/A Corrective Actions
413-215-0581(5) Completed
Individual written inventory of all personal
possessions is maintained and updated as X
needed
Records and Documentation Corrective Action
Yes No N/A Corrective Actions
413-215-0071 Completed
(1) Stored safely X
(2) Permanent, legible, dated, and signed X
(3)&(4) Uniform in organization, readily X
identifiable and accessible, current, and
complete, containing all required info. No
eraser tape or white out.
(7) Permanent registry for each child
includes:
Name X
Gender
Birth date
23
Names, addresses of parents or guardians
Dates of admission
Placement upon discharge
Counter Point (Day Treatment)
Educational Services Corrective Action
Yes No N/A Corrective Actions
413-215-0856 Completed
(1) Complies with the minimum requirements X
for private education as determined by Dept.
of Education
School is registered with Dept. of Education X
(if applicable)
School is accredited X
Accrediting body DART- Portland Public
(2) 1:15 ratio for qualified teacher/children X
(3) Curriculum meets OAR 581-022-1020 X
(4) Secondary schools – verification provided X
that meets academic standards to obtain
admission to higher education and receive
high school diploma or GED
Physical Plant Corrective Action
Yes No N/A Corrective Actions
Completed
413-215-0046(3)(a) Foster Rights Posted (if X Physical Plant 413-215-0816(2) Buildings are smoke free,
children in DHS custody) clean and in good repair.
413-215-0051(1) Sufficient safe space, X The following was identified in need of repair:
equipment, and office equipment. o Recreation/Music Room had two ceiling tiles that had
413-215-0816(8)(e) Adequate in size and X leaky water spots needing repair.
arrangement for programs offered
413-215-0091(12) License is posted in X
common area at each facility
413-215-0001(5)(d) & 0816(9)(a)&(b) X
Adequate furnishings and personal items;
storage for personal items
413-215-0816(2) Buildings are smoke free, X
clean and in good repair
413-215-0816(3) Rooms are free of harmful X
drafts, odors, and excessive noise
24
413-215-0816(4) Rooms are adequate in X
size and arrangement
413-215-0816(5) System provides a X
continuous supply of hot and cold water
413-215-0816(7) Building is well ventilated X
and room temperature is within a normal
comfort range
Bathrooms Corrective Action
Yes No N/A Corrective Actions
413-215-0816(8)(a) Completed
(A) 1:15 ratio for toilets X
(B) 1:2 ratio for sinks to toilets. Hand- X
washing sink not used for food prep
(C) Hot and cold running water, soap, and X
approved hand drying options
(D) Individual privacy X
(E) Permanently wired fixtures X
(F) Window covering X
(G) Mirror, permanently affixed X
(H) Adequate ventilation X
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions
Completed
413-215-0816(8)(A)(B) Laundry is separate X
from food storage, kitchen and dining
413-215-0816(8)(c) Separate storage areas X
are provided for food, kitchen supplies,
utensils, clean linens, soiled linens and
clothing, cleaning supplies and equip,
poisons, chemicals, outdoor recreational and
maintenance equipment
413-215-0816(8)(g) Recreational activity X
area is protected from vehicles and other
hazards and of a size and availability
appropriate to the age and needs of children
in care
413-215-0816(8)(f) Time out rooms have X
adequate space, heat, light and ventilation
and is not capable of locking
Food Service area Corrective Action
Yes No N/A Corrective Actions
413-215-0816(8)(d) Completed
(A) Areas used for storage, food preparation, X
and dish washing are separate from child-
caring areas
(B) Walls, floors are easily cleanable X
25
(C) Equipment and utensils are easily X
cleanable, durable, nontoxic, and kept clean
(D) Equipment is easy to clean beneath, X
between and behind
Food Services Corrective Action
Yes No N/A Corrective Actions
413-215-0831 Completed
(1)(a) Meals are arranged daily, consistent X
with normal mealtimes that occur during the
hours of operation
(b) Menus are prepared in advance in X
accordance with USDA guidelines, provide a
variety of foods and are adjusted for
seasonal changes.
(b) Menus are maintained for at least 6 X
months Lunch is catered by the school
district and brought in prepared.
(c) Drinking water is freely available X
(2)(a) Food is stored, prepared & served in a X
sanitary manner
(2)(c) & (d) Food products are obtained from X
commercial suppliers (exception of fruits &
vegetables), unpasteurized juice is
prohibited, and only Grade A pasteurized
and fortified milk in appropriate container.
Lunch is catered by the school district
and brought in prepared.
(2)(e) Children are supervised when in the X
food-preparation area
Safety Corrective Action
Yes No N/A Corrective Actions
413-215-0836 Completed
(2)(a) Written emergency plan X
(2)(b) Telephone numbers for local police X
and fire are posted near all telephones
(2)(c) Operative flashlights sufficient in X
number are readily available to staff
(3)(a) Evacuation drill occurs monthly X
under varying conditions, is retained 2
years and contains;
(A) identity of person conducting drill
(B) date & time
(C) notification method
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
26
(H) time to complete
(4) Children are protected from hazards and X
potential hazards
(4)(c) Light fixtures have protective covers X
Safety – Transportation Corrective Action
Yes No N/A Corrective Actions
413-215-0836(5) Completed
(b) Vehicle has insurance policy, is smoke X
free, safe operating condition, and has first
aid kit and fire extinguisher 2-A:10-BC
Medication Corrective Action
Yes No N/A Corrective Actions
413-215-0846 Completed
(2) & (5)(e) Medications have a prescription X
and are stored in the original container with
prescription label
(5) Medications are kept in locked storage X
(6) Medications are disposed in accordance X
with state and federal law
(7) Written record of the disposal of X
medications is maintained (description,
name, reason, method, staff & witness
signature)
(8) Written record of the administration of X
medication includes:
(a) name
(b) description
(c) dates & times
(d) missed doses
(e) medication disposed
(f) method of administration
(g) ID of person administering
(h) possible adverse reactions
(i) medication taken outside facility
Staff Qualifications and Minimum Staffing
Corrective Action
Requirements Yes No N/A Corrective Actions
Completed
413-215-0811
(1) Teachers are licensed in accordance with X
Teachers Standards and Practices
Commission
(2) A qualified clinical supervisor directs the X
clinical program and supervises clinical staff
(3) Mental health service delivery staff meet X
the qualifications in OAR 309-022-0125
(4) Sufficient QMHP and other staff to meet X
the severity and acuity of children served.
Does not exceed 1:12 QMHP
27
Current Ratios 4:15
413-215-0001(5)(f) Ensures safety and X
adequate supervision
413-215-0001(5)(c) Engages in and applies X
appropriate behavior management
techniques
Personnel Files Corrective Action
Yes No N/A Corrective Actions
413-215-0061 Completed
Name X
Position X
(3)(g) Date of Hire X
(3)(a) record of education, training and X
previous employment
(1)(b) & (3)(b) reference checks complete X
and documented
(1)(a) & (3)(c) Background check was X
completed and documented
(3)(d) Annual performance evaluations X
(3)(f) Record of personnel actions X
(3)(g) Termination date, reason for X
termination
(3)(h) Current job description (1)(c) X
Employee meets minimum qualifications
stated in current job description
New Employee Orientation- Umbrella
Corrective Action
Requirements (30 days) Yes No N/A Corrective Actions
Completed
413-215-0061(4)
(a) Agency policies and procedures X
(b) Ethical and professional guidelines X
(c) Organizational lines of authority X
(d) Attributes of population served X
(e) & (5)(a) to (c) Mandatory reporting that X
includes:
28
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter 106,
section 36
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
(f) Privacy laws X
(g) Emergency procedures X
Ongoing Training Corrective Action
Yes No N/A Corrective Actions
Completed
413-215-0831(2)(b) Employees who handle X
food served to children have a valid food
handler’s card
413-215-0061(5) Mandatory reporting X
(annually) that includes:
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter 106,
section 36
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
413-215-0836(5)(a) Employees transporting X
children meet the driver requirements
(current driver’s license, insurance, trained in
emergency procedures & behavior
management, and training for 15+
passenger vans if applicable)
Contractors (if applicable) Corrective Action
Yes No N/A Corrective Actions
413-215-0061(6) Completed
(a) Agency ensures the contractor meets the
requirements of this rule and Chapter 413 X
division 215
(b)(B) Contract includes the following:
(i) Services provided
(ii) Contractor fees
(iii) Disclosure of information from contractor
to agency
(iv) Lines of authority X
(v) Adherence to rules, including background
check
(vi) Any liability of the agency for acts of the
contractor, rights of indemnity and limitations
on liability
29
Children’s Records Corrective Action
Yes No N/A Corrective Actions
Completed
Name of Child X
Date of admission X
Medication Corrective Action
Yes No N/A Corrective Actions
413-215-0846 Completed
(3) Medical treatments, special diets, X
physical therapy, physical aides or
limitations have a written order signed by a
physician or qualified medical professional.
(4) Self-administration is approved in writing X
by Physician, recommended by agency, and
monitored by staff or guardian. (9) If
applicable, there is documentation of the
continuing evaluation of the ability of the
child to self-administer medication
(8) Medication record X
Records and Documentation Corrective Action
Yes No N/A Corrective Actions
413-215-0071 Completed
(1) Stored safely and are available for X
inspection by Dept.
(2) Permanent, legible, dated, and signed X
(3)&(4) Uniform in organization, readily X
identifiable and accessible, current, and
complete, containing all required info. No
eraser tape or white out.
(7) Permanent registry for each child
includes:
Name
Gender
X
Birth date
Names, addresses of parents or guardians
Dates of admission
Placement upon discharge
Treatment Foster Care
30
Medication Corrective Action
Yes No N/A Corrective Action
413-215-0381 Completed
(2) &(5)(e) Medications have a prescription X
and are stored in the original container with
prescription label
(3) Medical treatments, special diets, X
physical therapy, physical aids or limitations
have a written order signed by a physician or
qualified medical professional.
(4) Self-administering medications by a child X
is approved in writing by physician,
recommended by agency, and closely
monitored
(6) Medications are disposed in accordance X
with state and federal law
(7) Written record of the disposal of X
medications includes:
(a) description
(b) name
(c) reason
(d) method
(e) staff & witness signature
(10) Written record of the administration of X
medication includes:
(a) name
(b) description
(c) dates, times
(d) missed doses
(e) medication disposed
(f) method of administration
(g) ID of person administering
(h) possible adverse reactions
(i) medication taken outside facility
Placement of a Child by Agency Corrective Action
Yes No N/A Corrective Action
413-215-0356 Completed
(2) Placement is consistent with X
recommendations in the current home
assessment
(3) Home does not exceed: X
(a) 4:1 ratio approved proctor foster parent
(b) 7:2 ratio approved proctor foster parents
(c) 2 children under the age of 3
(6) At time of placement the agency provides X
proctor foster home parents with:
31
(a) Child’s name, date of birth and reason for
placement
(b) Name and phone# of assigned worker
(c) Information on health, behavioral
characteristics and needs of child
(d) Authorization and written instructions for X
obtaining medical, dental and other and
emergency care
Respite Care Corrective Action
Yes No N/A Corrective Action
413-215-0366 Completed
(1) Agency has and adheres to a respite care X
policy
(2)(a) Alternate caregivers are X
(A) at least 21 years of age and
(B) have completed background checks
(2)(b) Agency approval is received prior to X
using respite care
(2)(c) Proctor foster home notifies agency in X
advance when providing respite care that will
exceed max number of children authorized
(2)(d)&(e) Respite care plan for each child X
and includes emergencies
Records of Proctor Foster Homes Corrective Action
Yes No N/A Corrective Action
413-215-0351 Completed
Last Name of Proctor Foster Parent(s) X
(2)(a) Certificate that includes: age range of X
children, restrictions or limitations, and
statement that the home meets standards
established in these rules
(2)(b) & 413-215-0316(4) Notification of X
acceptance or denial of application. If denial
is due to substantiated abuse, the reason for
denial is disclosed to applicant.
(2)(d) All documents pertaining to formal X
complaints. See also 413-215-0336
(2)(e) and 413-215-0356(5) Signed contract X
(2)(f) List of all children placed that includes X
identifying and placement information
413-215-0356(4) Documentation of the basis
for placement
(2)(g) Documentation of home visit (every X
180 days)
32
(3) Documentation of changes in address, X
name and household composition, and
exceptions or suspensions
(4) Documentation of inactive status (if X
applicable)
413-215-0313(1)(a) at least 21 years of age X
413-215-0341 Written notice to proctor foster X
home if decertified
413-215-0349(1)-(7) Required notifications X
Assessment and Approval of Proctor
Foster Homes Corrective Action
N/A Corrective Action
Written Assessment Completed
413-215-0316
(1)&(2) Assessment is based on an on-site X
review of the home, observations and
interviews of each household member,
background check, any information gathered
during assessment.
(2)(a) Application signed by all applicants X
(2)(b) Home is primary residence and where X
each child will reside
(2)(c) Statement of physical and mental X
health
(2)(d) Report from licensed health care or X
mental health professional if determined
appropriate by agency
(2)(e) Minimum of 4 references (only one can X
be relative)
(2)(f) Contact information for 2 individuals if X
applicant displaced by natural disaster
Assessment and Approval of Proctor
Foster Homes
Corrective Action
Written Home Study includes the Yes No N/A Corrective Action
Completed
following:
413-215-0316(3)
(a) Standards for the Proctor Foster Home X
413-215-0318 – Safety Assessment
(CF0979) although form is no longer required
in rule, it may be accepted but must also
include evidence the following has been
addressed:
(1)(a) Home is primary residence
(1)(d) For children in custody of the
Department, the home must post and
33
comply with the Foster Children’s Bill of
Rights
(1)(g) Authorization must be received
from the agency prior to the beginning of
hunting or target practice by the child
(2)(a) If there are potential hazards in or
around the home, a plan to prevent
exposure of the child to the hazard must
be developed and approved by the
agency
(2)(a) Space heaters must be plugged
directly into a wall outlet and equipped
with top-over protection
(2)(d) Home and furnishings must be
clean and in good repair and grounds
must be maintained
(2)(e) No accumulation of garbage or
debris
(2)(f) Home has an adequate source of
safe water to be used for personal
hygiene
(2)(g) There is a provision for safe
storage and administration of all
medications in the household
(2)(i)(A)Children may not be exposed to
any second-hand smoke in home or
vehicle.
(2)(i)(B) Household members may not
provide any form of tobacco, nicotine, or
other product illegal for a minor to
possess
(2)(i)(C) All products referenced in (B)
must be stored safe and in a manner
inaccessible to children
(4)(d) Written authorization must be
received by proctor foster home prior to
transporting a child out of state or country
(4)(e) Proctor foster home must request
approval from Department no less than
90 days prior to international travel
(b) Names and ages of children in the home X
and children no longer in the home
(c) Background check for all household X
members over 18 and those under 18 as
determined appropriate
34
(d) Background check from every state (or X
country) of residence in last 5 years for
household members over 18 and those
under 18 as determined appropriate
(e) Placement preferences X
(f) Motivation for providing foster care X
(g) Life experiences and challenges X
(h) Relevant health history X
(i) Education and training X
(j) Employment and finances X
(k) Current support systems and need for X
additional support services
(l) Marital history, including previous X
marriages, divorces, and long-term
relationships
(m) Parenting skills and values X
(n) Lifestyle X
(o) Religion or spiritual beliefs X
(p) Cultural background and experiences X
with diverse cultural groups
(q) Ability to respect spiritual beliefs, sexual X
orientation, gender identity, and gender
expression, disabilities, national origin, and
cultural identities of each child and provide
opportunities to enhance the positive self-
concept and understanding of child’s
heritage
(r) Assessment of current and previous X
licenses, certifications and other applications
for providing care including adults.
Information must include any denials,
suspensions revocations, or terminations
35
(s) Assessment of the areas in which training X
is needed and the plan of the agency for
providing needed training and timeframes
(t) Applicant’s home and community X
(u) Assessment and recommendations X
including the characteristics and maximum
number of children who may be placed in
care
Annual Review and Approval Corrective Action
Yes No N/A Corrective Action
413-215-0331(2) Completed
(a) Updated home study X
(b) Background check(s) X
(d) Out of state background check (if X
applicable)
(e) Documentation that home remains in X
compliance with safety standards 413-215-
0318
(f) Recommendation to approve or deny re- X
issuance of certificate
Orientation for Proctor Foster Homes
Corrective Action
Applicants Yes No N/A Corrective Action
Completed
413-215-0321(2)
(a) & 413-215-0061(4)(a) Policies and X
procedures of the agency
(b) & 413-215-0061(4)(d) Attributes of X
population. Needs and characteristics of
children needing placement
(c) Attachment, separation, and loss issues X
for children and families
(d) Importance of cultural identity and ways X
to foster this identity
(e) Impact of foster care on child and family X
(f) Rights and responsibilities of proctor X
foster parent and agency
(g) Resources available X
(h) Confidentiality X
(i) Rights of families and children X
(j) Provided copies of X
(A) Program statement
(B) Requirements for Proctor Homes
(C) Policies of agency governing proctor
foster homes
(D) Training requirements
(E) Licensing rules
36
(F) Expectations for working with the
agency
Orientation – Umbrella Requirements (30
Corrective Action
days) Yes No N/A Corrective Action
Completed
413-215-0061(4)
(b) Ethical and professional guidelines X
(c) Organizational lines of authority X
(e) & (5)(a) to (c) Mandatory reporting that X
includes:
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter 106,
section 36
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
(f) Privacy laws X
(g) Emergency procedures X
Training for Parents in Proctor Foster
Care Corrective Action
Yes No N/A Corrective Action
Written Training Plan includes: Completed
413-215-0326(1)
(a) Minimum of 15 hours of training before X
placement
(b) Minimum of 15 hours training annually X
prior to approval
(c)(A) Characteristics and needs of children X
who are placed
(c)(B) Ways to effectively parent children, X
including application of the reasonable and
prudent parent standard
(c)(C) Positive behavior management X
(c)(D) Importance of family of the child and X
working with the family
(c)(E) Importance of age-appropriate or X
developmentally appropriate extracurricular,
enrichment, cultural, and social activities
(c)(F) Preparation of child for independence X
based on age, stage of development, and
child’s needs
(c)(G) Legal responsibility to report X
suspected child abuse
(2) Training is documented X
37
Personnel Files Corrective Action
Yes No N/A Corrective Action
413-215-0061 Completed
Staff Name X
Position X
(3)(g) Date of Hire X
(3)(a) record of education, training and X
previous employment
(1)(b) & (3)(b) reference checks completed X
and documented
(1)(a) & (3)(c) Background check X
completed and documented
(3)(d) Annual performance evaluations X
(3)(f) Record of personnel actions X
(3)(g) Termination date, reason for
X
termination
(3)(h) Current job description X
New Employee Orientation – Umbrella
Corrective Action
Requirements (30 days) Yes No N/A Corrective Action
Completed
413-215-0061(4)
(a) Agency policies and procedures X
(b) Ethical and professional guidelines X
(c) Organizational lines of authority X
(d) Attributes of population served X
(e) & (5)(a) to (c) Mandatory reporting X
(annually) that includes:
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter
106, section 36
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal
to the employee
(f) Privacy laws X
(g) Emergency procedures X
New Employee Orientation – Foster
Corrective Action
Care (30 days) Yes No N/A Corrective Action
Completed
413-215-0371
38
(1)(a) Discipline and behavior management X
including de-escalation, crisis prevention,
positive behavior management, and
disciplinary techniques that are non-
punitive in nature
(1)(b) Restraint and seclusion (if X
applicable)
Ongoing Training Corrective Action
Yes No N/A Corrective Action
Completed
413-215-0371(2)(a) Environmental X
emergencies
413-215-0371(2)(b) Universal Precautions X
413-215-0371(2)(c) Discipline and X
Behavior Management
413-215-0371(3) Maintain current X
CPR/First Aid certification
413-215-0371(4) Training related to the X
reasonable and prudent parent standard
and developmentally appropriate activities
413-215-0061(5) Mandatory reporting that X
includes:
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter
106, section 36
(b) legal responsibility to immediately
report
(c) legal responsibility to report is personal
to the employee
Contractors (if applicable) Corrective Action
Yes No N/A Corrective Action
413-215-0061(6) Completed
(a) Agency ensures the contractor meets
the requirements of this rule and Chapter X
413 division 215
(b)(B) Contract includes the following:
(i) Services provided
(ii) Contractor fees
(iii) Disclosure of information from
X
contractor to agency
(iv) Lines of authority
(v) Adherence to rules, including
background check
39
(vi) Any liability of the agency for acts of
the contractor, rights of indemnity and
limitations on liability
Children’s Records Corrective Action
Yes No N/A Corrective Action
Completed
Name
X
Initial Evaluation Corrective Action
Yes No N/A Corrective Action
413-215-0386(2) Completed
(a) Agency request and review all available X
reports of child’s past and present
behavior, educational status, and physical
and mental health.
(b) Preliminary determination whether X
prospective child has disorders,
disabilities, or deficits for which care,
supervision, training, rehab, or treatment is
needed
Information about Children in Care
Corrective Action
413-215-0396 (1) Summary sheet Yes No N/A Corrective Action
Completed
contains the following:
(a)The name, gender, date of birth, X
religious preference, and previous address
(b) Name and location of previous and X
current school
(c) Date of admission X
(d) Legal custody X
(e) The name, address, and telephone X
number of:
(A) The child's parents.
(B) The child's legal guardian, if
different than parents, and legal
relationship
(C) Other persons significant to child
(D) Other professionals to be involved
in service planning (if applicable)
(f) Required consents and authorizations X
Health Services Corrective Action
Yes No N/A Corrective Action
413-215-0376 Completed
(2) Medical history obtained within 30 days X
(a) significant findings
40
(b) current immunizations, history of
surgical procedures-health issues-injuries
(c) allergies
(d) dental, vision, hearing, behavioral
health, and
(f) physician orders
(2)(e) Documentation of age appropriate X
instruction – pregnancy prevention,
nutrition, prevention of HIV & AIDS, and
prevention and treatment of sexually
transmitted disease
(3) Agency provides or arranges for X
(a) information on maintaining reproductive
health and birth control
(b) prenatal care
(c) well baby care
(d) fetal alcohol syndrome
(e) accessing health insurance
(f) cancer screenings
(g) feminine hygiene products
(h) access to birth control and vaccinations
(4)(a) to (f) Medical exams (3 in first year
of life, 2,4,6,9,14) X
Consents Corrective Action
Yes No N/A Corrective Action
413-215-0391(1) Completed
(a) Provide routine and emergency X
medical care
(b) Use the discipline and behavior X
management system
(c) Use restraint or seclusion (if X
applicable). Must specify the reasons for
the intervention and how staff and proctor
foster home parents are trained and
supervised
(d) Restrict contact with persons outside of X
the agency
(e) Allow access as defined in 413-215- X
0091 & 0101
(f) Impose a dress code X
(g) Apply the reasonable and prudent X
parent standard
41
Disclosures
Corrective Action
413-215-0391(2) Parent/guardian has Yes No N/A Corrective Action
Completed
acknowledged in writing:
(a) Mandatory child abuse reporting X
requirements
(b) Information regarding personal or room X
searches and protocols for confiscation of
contraband
(c) Statement of Rights of Children and X
Parents/Guardians
(d) Grievance policies and procedures X
(e) Any policies and procedures upon X
request
Authorizations Corrective Action
Yes No N/A Corrective Action
413-215-0391(3) Completed
(a) Disclose information X
(b) Child specific visitors X
(c) Visitation resources are pre-approved X
(d) Activity specific authorizations are pre- X
approved to allow children to participate in
potentially hazardous activities, including
but not limited to using motorized yard
equipment, swimming, and horseback
riding.
Service Planning Corrective Action
Yes No N/A Corrective Action
413-215-0396(2) Completed
(a) All documentation written in terms that X
are easily understood
(b) Intake document is completed the date X
child accepted into care (emergency
placement 48 hours)
(c) Child is served according to an X
individual service plan that outlines goals
for services and care coordination
(d) Assessment is completed within 30 X
days and contains relevant historical info.,
current behavioral observations, identified
need for services, and how agency will
provide or coordinate services
(e) (A)&(B) Service plan within 60 days X
(parent, guardian and child actively
involved). Describes how child’s issues will
42
be addressed, anticipated outcomes and
reviewed by child and guardian/parent.
(e)(C)&(D) Service plan is reviewed X
quarterly and revised when information
indicates other services should be
provided
Case Management Corrective Action
Yes No N/A Corrective Action
413-215-0396(3) Completed
(a) Services are documented, progress X
toward achieving goals is tracked
(b)-(d) discharge planning and instructions X
(e) Follow-up services identified (if X
applicable)
(f) Incident Reports X
Financial Records Corrective Action
Yes No N/A Corrective Action
413-215-0396(4) Completed
Records contain (if applicable)
(a) date, amount,
(b) source X
(c) purpose
(d)&(e) signatures
Personal Possessions Records Corrective Action
Yes No N/A Corrective Action
413-215-0396(5) Completed
Individual written inventory of all personal
possessions is maintained and updated as X
needed
Records and Documentation Corrective Action
Yes No N/A Corrective Action
413-215-0071 Completed
(1) Stored safely X
(2) Permanent, legible, dated, and signed X
(7) Permanent registry for each child in X
care includes (name, gender, birth date,
names, addresses of parents or guardians,
dates of admission, and placement upon
discharge)
*Supplemental information provided by the CCA as stated above (page 13).
All revisions made to policies must be highlighted prior to sending to Licensing. Required Policy
Revisions:
43
413-215-0046 Licensing Umbrella Rules: Children and Families Rights Policy and Grievance Procedures (Amended 1/1/19)
(1) Rights of children in care and families served by the child-caring agency. A child-caring agency must guarantee the rights of children in care and the
families the child-caring agency serves. A child-caring agency must enact and adhere to a policy ensuring those rights. A written copy must be distributed
to all children in care and families served by the child-caring agency, and afford the following rights: (a) Except as provided in paragraph (B) of this
subsection, the child in care's right to uncensored communication with legal guardians, caseworkers, legal representatives, and other persons approved for
communication by the legal guardian or as provided in a court order. (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: (D) The name, address, and phone number of: (i) A Department licensing coordinator; and (ii) Any other
governmental entities with oversight responsibilities.
The program was missing the above requirements in the Child and Families Rights Policies, and must be added:
 Counterpoint: The Counterpoint Policy was missing the above required information regarding uncensored communication.
The program was missing the above requirements in the Grievance Policies, and must be added:
 Foster Care: The Foster Care Policy was missing the above required information for the Grievance Policy, and must be updated to include Jorge
Pelinski’s (ODHS Licensing Coordinators) name and contact information.
413-215-0073 Licensing Umbrella Rules: Discipline, Behavior Management & Training, and Suicide Prevention
(Excluding Adoption Agencies) (Adopted 07/01/2022) (1) A child-caring agency, except a child-caring agency licensed only to provide adoption
services under OAR 413-215-0401 to 413-215-0481, must adopt and adhere to written policies and procedures on discipline, behavior management, and
suicide prevention that meet all of the requirements of this rule. (b) The discipline and behavior management policies and procedures must prohibit the
following: (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. (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. (K) Removing or limiting the use of a
mobility aid or other assistive device for the purpose of controlling a child in care's behavior. (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. (4) Suicide Prevention. The policy must include the
following: (f) Suicide risk assessment procedures on the day of intake; (g) Documentation requirements for suicide ideation, self-harm, and special
observation precautions to ensure immediate communication to all staff
The programs were out of compliance with some of the above requirements for Behavior Management Policies, and the following must be added:
44
 Sage:1(K)
 LTGH: 1(A-K), 3(C)(i)
 ORR:1(A-K), 3(C)(i)
 Counterpoint: 1(K)
 Foster Care:1(J)(K)
The programs were out of compliance with some of the above requirements for Suicide Prevention Policies, and the following must be added:
 LTGH:4(f)
 ORR: 4(g) Missing ”…. to ensure immediate communication to all staff”
413-215-0077 Licensing Umbrella Rules: Restraints and Involuntary Seclusion
(Amended 07/01/2022) (1) A child-caring agency may only place child in care in a restraint or involuntary seclusion if the child in care’s behavior poses a
reasonable risk of imminent serious bodily injury to the child in care or others and less restrictive interventions would not effectively reduce the risk. (2) A
child-caring agency may not place a child in care in a restraint or involuntary seclusion as a form of discipline, punishment, or retaliation or for the
convenience of staff, contractors or volunteers of the child-caring agency. (3) If the child-caring agency utilizes restraints or involuntary seclusion as part of
its practices, its use of restraints and involuntary seclusion must be in compliance with all applicable federal and state laws, regulations and rules. (4) A
child in care placed in a restraint or involuntary seclusion must be continuously monitored by staff of the child-caring agency for the duration of the
restraint or involuntary seclusion. (5) Any restraint or involuntary seclusion used on a child in care must be performed in a manner that is safe,
proportionate and appropriate, taking into consideration the child in care’s chronological and developmental age, size, gender identity, physical, medical
and psychiatric condition and personal history, including any history of physical or sexual abuse. (6) The removal or limitation of the use of a mobility aid
or other assistive device in a restraint is prohibited unless there is a risk of imminent serious bodily injury and less restrictive interventions would not
effectively reduce the risk. (7) Removing or limiting the use of a mobility aid or other assistive device for the purpose of controlling a child in care’s
behavior is prohibited and (8) If any restraint or involuntary seclusion lasts for more than 10 minutes, the child-caring must provide adequate access to the
bathroom and water at least every thirty minutes to the child in care. (9) For any restraint or involuntary seclusion lasting more than 10 minutes a
supervisor, trained in the non-violent crisis intervention system used by the child-caring agency must provide written authorization for the continuation of
the restraint or involuntary seclusion every five minutes. (a) If the supervisor is not on-site at the time the restraint is used, the supervisor may provide the
written authorization electronically. (b) The written authorization must document why the restraint or involuntary seclusion continues to be the least
restrictive intervention to reduce the risk of imminent serious bodily injury in the given circumstances. (10) Restraint. (a) The following types of restraint of
a child in care are prohibited: (A) Chemical restraint. (B) Mechanical restraint. (C) Prone restraint. (D) Supine restraint, except: (i) Supine restraint may be
used only when the child in care is currently admitted to a secure children’s inpatient treatment program or secure adolescent inpatient treatment
program…(E) Any restraint that includes the nonincidental use of a solid object, including the ground, a wall or the floor, to impede a child in care’s
movement, except: (i) This type of restraint may be used if the restraint is necessary to gain control of a weapon or; (F) Any restraint that places or creates a
risk of placing pressure on a child in care’s neck or throat. (G) Any restraint that places or creates a risk of placing, pressure on a child in care’s mouth,
except: (i) This type of restraint may be used if the restraint is necessary for the purpose of extracting a body part from a bite. (H) Any restraint that
impedes, or creates a risk of impeding, a child in care’s breathing. (I) Any restraint that involves the intentional placement of hands, feet, elbows, knees or
any object on a child in care’s neck, throat, genitals or other intimate parts. (J) Any restraint that causes pressure to be placed or creates a risk of causing
pressure to be placed, on a child in care’s stomach, chest, joints, throat or back by a knee, foot or elbow. (K) Any other restraint which the primary purpose
is to inflict pain. (b) Permissible use of restraint. A restraint may be used on a child in care in the following situations: (A) Holding a child in care’s hand or
45
arm to escort the child in care safely and without the use of force from one area to another; (B) Assisting the child in care to complete a task if the child in
care does not resist the physical contact; or (C) Using a physical intervention if: (i) The intervention is necessary to break up a physical fight or to
effectively protect a person from an assault, serious bodily injury or sexual contact; (ii) The intervention uses the least amount of physical force and contact
possible: and (iii) The intervention is not a prohibited restraint identified in OAR 413-215-0077(8)(a). (c) Only child-caring agency staff and proctor foster
parents who have been trained in a nationally recognized nonviolent crisis-intervention system may use restraint and only when necessary, as a last resort to
prevent a child in care from inflicting harm to self or others. The restraint must be conducted within the parameters of the nationally recognized system in
which the staff or proctor foster parent is trained. (d) Any use of restraint by a staff member or proctor foster parent of the child-caring agency, if the
member is not trained in a nationally recognized nonviolent crisis intervention system, must also be reported to a Department licensing coordinator within
one business day of occurrence. (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. (12) Records (a) A program shall maintain a record of each incident in which a reportable injury arises from the use of a restraint or involuntary
seclusion. The record must include any audio or video recording immediately preceding, during and following the incident. (b) If a program places a child
in care in a restraint, except as described in OAR 413- 215-0077(8)(b)(A) or 413-215-0077(8)(b)(B) or involuntary seclusion, the program shall provide the
child in care’s case manager, attorney, court appointed special advocate and parent or guardian with: (A) Verbal or electronic notice that the restraint or
involuntary seclusion was used as soon as practicable following the incident but not later than the end of the next business day; and (B) Written notice in
compliance with OAR 413-215-0077(10)(c) that the restraint or involuntary seclusion was used as soon as practicable following the incident but not later
than the end of the next business day.(c) The written notice must include: (A) A description of the restraint or involuntary seclusion, the date of the restraint
or involuntary seclusion, the times when the restraint or involuntary seclusion began and ended and the location of the restraint or involuntary seclusion; (B)
A description of the child in care’s activity that necessitated the use of restraint or involuntary seclusion; (D) The names of each of individual who placed
the child in care in the restraint or involuntary seclusion or who monitored or approved the placement of the child in care in the restraint or involuntary
seclusion; (i) For each individual identified whether the individual was trained, as required by the Department of Human Services by rule, in the use of the
type of restraint or involuntary seclusion used, the date of the individual’s most recent training and a description of the types of restraint the individual is
trained to use, if any. (ii) If an individual identified was not trained in the type of restraint or involuntary seclusion used, or if the individual’s training was
not current, a description of the individual’s training deficiency and the reason an individual without the proper training was involved in the restraint or
involuntary seclusion. (d) If an incident requires notice under 413-215-0077(b), not later than two business days following the date of the restraint or
involuntary seclusion, the program shall hold a debriefing meeting with each individual who was involved in the incident and with any other appropriate
program staff, shall take written notes of the debriefing meeting and shall provide copies of the written notes to the child in care’s case manager, attorney,
court appointed special advocate and parents or guardians. (e) If a program places a child in care in a restraint or involuntary seclusion and the child in care
suffers a reportable injury arising from the restraint or involuntary seclusion, the program shall immediately provide the department and the child in care’s
attorney, court appointed special advocate and parents or guardians with written notification of the incident and access to and, upon request, copies of all
records related to the restraint or involuntary seclusion, including any photographs and audio or video recordings. (f) If serious bodily injury or the death of
staff occurs in connection to the use of the restraint or involuntary seclusion, the program shall provide the department with written notification of the
incident not later than 24 hours following the incident.
The programs were out of compliance with some of the above requirements for Restraint Policies, and the following must be added:
 Sage: (1)”….less restrictive interventions would not effectively reduce the risk.” (2), (3), (5), (6), (7), (8), (9)(a)(b),
(10)(a)(A)(B)(C)(D)(E)(i)(F)(G)(H)(I)(J)(K)(b)(A)(B)(C)(i)(ii)(iii)(c)”….. nonviolent crisis-intervention system may use restraint and only when
necessary, as a last resort to prevent a child in care from inflicting harm to self or others. The restraint must be conducted within the parameters of
46
the nationally recognized system in which the staff or proctor foster parent is trained.”(d) (12)(a)(b)(A)(B)(c)(A)” the date of the restraint….. and
the location of the restraint”(B)(D)(i)(ii)(d)( e)(f)
 LTGH: (3),(4),(6),(7), (8), (9)(a)(b), (10)(a)(A)(C)(D)(E)(i)(F)(G)(i)(H)(I)(J)(K)(b)(A)(B)(C)(i)(ii)(iii) )(c)”….. nonviolent crisis-intervention
system may use restraint and only when necessary, as a last resort to prevent a child in care from inflicting harm to self or others. The restraint must
be conducted within the parameters of the nationally recognized system in which the staff or proctor foster parent is trained.”(d)( e)
12(a)(b)(A)(B)(c)(A) )” the date of the restraint….. and the location of the restraint” (D)(i)(ii)(d)(e)(f)
 ORR: (3),(4),(6),(7), (8), (9)(a)(b), (10)(a)(A)(C)(D)(E)(i)(F)(G)(i)(H)(I)(J)(K)(b)(A)(B)(C)(i)(ii)(iii) )(c)”….. nonviolent crisis-intervention system
may use restraint and only when necessary, as a last resort to prevent a child in care from inflicting harm to self or others. The restraint must be
conducted within the parameters of the nationally recognized system in which the staff or proctor foster parent is trained.”(d)( e)
12(a)(b)(A)(B)(c)(A) )” the date of the restraint….. and the location of the restraint” (D)(i)(ii)(d)(e)(f)
 Counterpoint: The Behavior Policy states that the program does not utilize restraints. The restraint policy must be revised to add verbiage, that at
no time should a restraint be utilized on youth in the program. Notwithstanding policy to not use physical restraints, the policy should indicate that
if a staff physically intervenes in an extreme circumstance, all reporting requirements, and timelines in OAR 413-215-0077 (10)(11) will be met as
required by SB710. In addition, the policy must state who from the program will ensure reporting requirements are met and the required debrief
meeting occurs in accordance with OAR 413-215-0077 (10)(d).
 Foster Care: The Behavior Policy states that the program does not utilize restraints. The restraint policy must be revised to add verbiage, that at no
time should a restraint be utilized on youth in the program. Notwithstanding policy to not use physical restraints, the policy should indicate that if a
staff physically intervenes in an extreme circumstance, all reporting requirements, and timelines in OAR 413-215-0077 (10)(11) will be met as
required by SB710. In addition, the policy must state who from the program will ensure reporting requirements are met and the required debrief
meeting occurs in accordance with OAR 413-215-0077 (10)(d).
413-215-0078 Licensing Umbrella Rules: Information Provided to Children in Care
(Adopted 02/01/2022 (1) Each child in care receiving services from a child-caring agency must be given the following: (a) Instruction regarding how a child
in care may report suspected inappropriate use of restraint or involuntary seclusion; (b) Assurance that the child in care will not experience retaliation for
reporting suspected inappropriate uses of restraint or involuntary seclusion and; (c) The telephone number for the toll-free child abuse hotline described in
ORS 417.805 and the telephone numbers and electronic mail addresses for the program’s licensing agency, the child in care’s caseworker and attorney, the
child in care’s court appointed special advocate and Disability Rights Oregon. (2) The information must be provided by: (a) The Department of Human
Services if the department placed the child in care in the child-caring agency; (b) The Oregon Youth Authority if the child in care has been committed to the
custody of the authority; or (c) The child-caring agency for all other children in care.
 Documentation was not found to verify that the agency had provided the above required information to the youth in all Morrison Programs at
admission.
47
413-215-0311 Foster Care Agencies: License Requirements (Amended 12/01/19) (3) In addition to the requirements in OAR 413-215-0001
to 413-215-0131, to be licensed by the Department, a foster care agency must:(c) Have policies and procedures describing the level of oversight the foster
care agency will provide to each proctor foster home that include: (A) The frequency of site visits to each proctor foster home. (B) How site visits will be
documented. (C) When and how the foster care agency will provide increased oversight to a proctor foster home. (D) How often a child in care will have
face-to-face contact and with whom.
 Foster Care: The Foster Care Policy was missing the above required information.
413-215-0381 Foster Care Agencies: Medication (Amended 12/01/19) A foster care agency must comply with all of the following
requirements: (1) Policy and procedures. The foster care agency must have policies and procedures that cover prescriptions, herbal remedies, and all non-
prescription medications that address all of the following: (h) How the foster care agency and the proctor foster home will ensure compliance with OAR
413-070-0470 if it serves children in Department custody.
 Foster Care: The Medication Policy was missing the above required information.
413-215-0551 Medication (Technical Amended 01/13/20) A residential care agency must meet all of the following requirements: (1) Policy and
procedures. The residential care agency must have policies and procedures that cover all prescription and non-prescription medications that address all of
the following: (h) How the foster care agency and the proctor foster home will ensure compliance with OAR 413-070-0470 if it serves children in
Department custody.
 Sage: The Medication Policy was missing the above required information.
413-215-0571 Referral and Initial Evaluation of Children (Technical Amended 01/14/20) (1) Referral. A residential care agency must have
a policy that addresses the process by which children in care are referred to the residential care agency. The policy must include all of the following: (a)
From whom referrals are accepted. (c) How information necessary to provide for the safety and care of children in care will be provided to the appropriate
care staff
 Sage: The Referral Policy was missing the above required information.
413-215-0576 Consents, Disclosures, and Authorizations (Amended 02/01/2022) (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: (a) To provide routine and emergency medical care. However, if the parent or legal guardian relies on prayer or spiritual
means for healing in accordance with the creed or tenets of a well-recognized religion or denomination, the residential care agency is not required to use
medical, psychological or rehabilitative procedures, unless the child in care is old enough to consent to these procedures and does so. The residential care
agency must have policies and procedures for this practice, which are reviewed and approved by the child in care's parent or legal guardian.
 ORR and LTGH: The Consent Policies were missing the above required information.
48
413-215-0846 Day Treatment Agencies: Medication (Technical Amended 01/15/20) A day treatment agency must comply with all of the
following requirements: (1) Policy and procedures. The day treatment agency must have policies and procedures that cover prescriptions, herbal remedies,
and all non-prescription medications that address all of the following: (a) How the medication will be administered. (b) By whom the medication will be
administered. (c) How the staff of the day treatment agency who administer medication will be trained. (d) How the administration of medication will be
documented. (e) How the administration of medication will be monitored. (f) How unused medication will be disposed of. (g) The process that ensures that
each child in care's prescription and non-prescription medications are reviewed, unless the medications are all provided through a single pharmacy. As used
in this rule, "non-prescription medication" means any medication that does not require a written prescription for purchase or dispensing.
 Counterpoint: The Medication Policy was missing the above required information.
Licensing Coordinator’s Signature: ________________________ Date: ___1__-1_7_-_2_0_2_3_ _______
Licensing Coordinator’s Signature: ________________________ Date: ____1_-1_3__-2_0_2_3__ ______
Manager Review: ______________________________________ Date: ___1_-_1_1_-_2_0_2_3_ ______
49

report_type: License Renewals

program_compliance:
The program is or will be compliant with OAR 413-215-0001 through 0131 Licensing Umbrella Rules, OAR 413-215-0301
through 0396 Licensing Foster Care Agencies, OAR 413-215-0501 through 0586 Licensing Residential Care and OAR 413-215-0801 through 0856
Licensing Day Treatment.
Personnel records were reviewed and compliance with required background checks was documented for employees in all programs.
Agency Description(s) as provided by Morrison:
Morrison Child and Family Services was founded in 1947, by Carl V. Morrison, who was a psychologist in Portland. It has grown to be a large
organization with a projected annual budget of around 33 million, and they employ approximately 414 employees. Morrison Child and Family
Services served 10,996 children in and families in 2021-2022. Morrison has programs that are licensed by Oregon Department of Human Services
(ODHS) Licensing and outpatient programs that are not.
Individual Program Description(s):
Planned and Crisis Respite Care (PCRC)- Provides planned or emergency short-term overnight respite services for children 3-17 years old.
Respite providers are certified Therapeutic Foster Parents through Morrison. The providers have been screened and specially trained to work with
children and youth who have a history of mental illness and may have been impacted by trauma. Respite homes provide a safe, supportive and
structured environment in which youth can take advantage of new opportunities. The average length of stay in 2020 was 2 days and the service is
primarily utilized on weekends.
Therapeutic Foster Care-
Morrison's Therapeutic Foster Care (TFC) program provides a safe and nurturing environment with care provided by specially screened parents
who are trained to work with children and youth impacted by trauma. TFC children and youth are 3-17 years old living in the Portland-Metropolitan
area and have been referred by their Child Welfare Caseworker for Therapeutic Foster Care because of clinical and behavioral issues that require
specialized care. Morrison's TFC program is contracted to provide care for up to 12 children. Often youth participating in TFC have experienced
multiple attachment disruptions and have suffered neglect as well as severe physical, sexual and emotional trauma. As a result, they can
experience mental health and behavioral issues that make it difficult for them to cope with daily routines and relationships. The average length of
stay in 2021 was 448 days. At the Licensing Review it was reported there were 5 certified foster homes, with a capacity of to serve 6 children.

Counterpoint Day Treatment -This program was founded in 1983. The Counterpoint Day Treatment and Proctor Care Program is a
comprehensive program that combines mental health and sexual offending treatment approaches with an accredited school program and proctor
care. The day program is open 8:45 am to 4:00 p.m. Monday-Friday and serves adolescent boys 12 to 17 years old that have sexual behavior
difficulties. Proctor homes provide care, support and supervision evenings and weekends for youth in OYA custody. Youth can be referred through
various sources: families, DHS, school, although most are referred by the Oregon Youth Authority Staff. Treatment services occur throughout the
day and include peer group meetings, offender accountability groups, abuse survivor/personal history groups, alcohol and drug education groups,
alcohol and drug treatment groups and behavioral skills groups. Group skills training also includes sex education, anger management,
assertiveness training and healthy relationships. Youth have access to individual and family counseling, medical care, case management and
psychiatric services. A full range of adolescent substance use treatment and recovery services are provided when needed. This program focuses
on teaching positive, age-appropriate social skills while helping clients to resolve personal issues and cope with earlier trauma. Research indicates
that early intervention with adolescents can eliminate future sexual offenses as well as significantly decrease the likelihood of social, emotional and
developmental problems from developing later in their lives. The school day is provided by Portland Public School teaching staff. Cognitive-
behavioral treatment strategies and interventions are used throughout the program.
Counterpoint Foster Care - Youth live in proctor care homes specifically recruited and supported by Morrison to provide a therapeutic home
environment. Proctor parents are certified through the Oregon Youth Authority. Proctor parents receive training, supervision, and support by
Morrison Staff. Proctor parents are highly involved in care planning and receive information daily from day treatment staff about youth progress and
behavior. Counterpoint staff provide monthly home visits and home inspections to provide feedback and support for proctor parents. Proctor
parents also receive individualized coaching when they request additional support, when youth needs increase or change significantly and when
staff assess that increased supervision would be beneficial. For safety and therapeutic reasons, no young children are placed in these homes. At
the Licensing Review it was reported there were 5 certified homes with a capacity to serve 14 children. The average length of stay for youth in care
during 2022 was 457 days.
Downtown Shelter - The Downtown Shelter is a 50-bed youth shelter located in downtown Portland that serves immigrant youth, 13-17 years old.
Both males and females are served but housed in separate areas of the facility. The Program opened July 2014. It provides temporary housing in
a supervised living environment, 6 hours of education per day and case management services designed to support the re-unification process.
Referrals are made to community resources for outpatient medical, dental and mental health services. Supportive counseling services are also
provided by Downtown Shelter clinicians when needed. The primary goal of the Program is for children to be placed with family members or an
identified sponsor. Services are designed to achieve this goal. The Downtown Shelter program provides residential services in partnership with the
US Department of Health and Human Services, Administration for Children and Families, Office of Refugee and Resettlement (ORR). All services
are planned and coordinated with ORR Federal Field Specialists acting as legal guardians. Youth are referred to the Shelter based upon an
assessment of their developmental and behavioral needs that indicates that they can function safely and successfully in an open, less restrictive
2
environment. Individual service needs and level of care is reviewed frequently (every 30 days) with the ORR Federal Field Specialist. In this model
influenced by child welfare practices, Morrison does not make initial placement, transfer or discharge decisions but acts as a care provider and
advocate for the youth. The population served is primarily immigrant youth from Central and South America who have entered the United States
without parents or legal guardians and without a legal immigration status. The youth typically speak Spanish or indigenous languages spoken in
their home countries. The average length of stay in 2022 was 30 days.
Long Term Group Home-The Long-Term Group Home is a residential program serving immigrant youth, 13-17 years old. It is co-located with the
Morrison Downtown Shelter Program but has separate physical space and staffing. The Program opened in April 2017. The Long-Term Group
Home program provides residential care, health care follow-up, socialization/recreation, life skills training and development, access to legal
services, case management services and mental health counseling, if needed. Youth placed in the program attend Lincoln High School during the
day and return to the Program after school and extra-curricular activities are completed. All services are coordinated closely with ORR Federal
Field Specialists who act as legal guardians. In this model influenced by child welfare practices, Morrison does not make placement or discharge
decisions, but acts as a care provider and advocate for youth served. Immigrant youth served within the Long-term Group Home program do not
typically have serious behavioral or developmental concerns. They require a long-term placement, usually 6-9 months, because there is not an
identified family member or adult sponsor to act as a legal guardian in the US. Consequently, programmatic and system goals are to assist youth in
understanding and adjusting to their legal status and prepare for independent living. Family or sponsor re-unification remains a goal if it is possible
to achieve. Services provided are community-based, supportive, and "as-needed". Youth attend a public high school and participate in extra-
curricular high school activities without direct, face-to-face supervision from program staff. They receive less frequent case management services
and utilization of supportive counseling services is not required. Additional criteria for placement within the Long-term Group Home include: being
under the age of 17.5 years at the time of placement and potential eligibility for "immigration" or "legal" relief. The population served are primarily
youth from Central or South America who speak Spanish and indigenous languages spoken in their home countries. They have entered the United
States without a parent or legal guardian and without legal immigration status. The average length of stay in 2022 was 149 days
SAGE Residential - The Support, Achieve, Grow, and Empower (SAGE) Program serves Commercially Sexually Exploited Children (CSEC) who
have been identified as needing intensive services to prevent future victimization. The secure residential setting allows staff to build a relationship
with each youth while engaging them in services. The foundation of the CSEC program is the Sanctuary Model, and the milieu utilizes Collaborative
Problem Solving. SAGE serves female identifying youth, ages 11 to 16.5, who are residents of the state of Oregon and have experienced
commercial sexual exploitation. The program is designed to last 11 to 14 months. It includes a full range of mental health treatment (individual,
group, family, psychiatric), substance abuse treatment, milieu therapy, on site education, medical case management services and education and
treatment specific to commercial sexual exploitation and sex trafficking. Portland Public Schools provides an on-site school. Their contract with
Oregon Health Authority is for 12 youth, ages 11-16.5, but the program has the capacity to serve 26 youth ages 10-17. The average length of stay
in 2022 was 231 days.

average_length_of_stay: The average length of stay was identified by program managers. Planned Crisis Respite Foster Care: (Primarily this service is only utilized on weekends) - 2021- 2-3 days - 2022- 2-3 days Foster Care Program: - 2021- 448 days - 2022- 268 days Counterpoint: - 2021- 321 days - 2022- 457 days SAGE: - 2021 315 days - 2022 231 days Residential Care Program Update-Long Term Group Home: - 2021- 95 days - 2022- 149 days Residential Care Program Update-Shelter: - 2021- 33 days - 2022- 30 days

average_daily_population_served: The average daily population was identified by program managers. Planned Crisis Respite Foster Care: - 2021- 62 children - 2022- 50 children Foster Care Program: - 2021-5 children - 2022- 4 children Counterpoint: 4 - 2021-8 children - 2022- 22 children SAGE: - 2021-16 children - 2022- 14 children Residential Care Program Update-Long Term Group Home: - 2021-11 children - 2022-18 children Residential Care Program Update-Shelter: - 2021-9 children - 2022- 12 children

number_of_children_served_annually: Number of children served was identified by program managers. Planned Crisis Respite Foster Care: - 2021- 93 children - 2022-82 children Foster Care Program: - 2021-11 children - 2022-6 children Counterpoint: - 2021- 16 children - 2022- 18 children SAGE: - 2021-33 children - 2022- 33 children Residential Care Program Update-Long Term Group Home: - 2021-10 children - 2022- 22 children Residential Care Program Update-Shelter: - 2021- 101 children - 2022-155 children

use_of_seclusion_or_restraint: Morrison programs prohibit seclusion. Staff at the following programs are trained in Non-violent Crisis Intervention (NCI) as restraints are allowed in emergency situations: The Downtown Long-Term Group Home and Shelter. SAGE Staff are trained in the Mandt 5 Intervention System. Counterpoint Day Treatment, and Morrison Foster Care are "hands off" programs. The staff are trained in NCI's non-physical interventions and de-escalation techniques.

interviews_observations:
Interviews: At the Licensing Review fifteen staff members, two foster parents and six children were interviewed. The following information was
gained during the interviews with the children:
- Many children reported appreciating the staff. Some children preferred some staff over other staff.
- The children all reported being able to talk to people on their approved contact list.
- The Sage youth interviewed desired more outdoor time, stating they aren't able to go outside every day. The Licensing Coordinator spoke
to the Program Manager, Kelli Doolittle, and Program Supervisor, Allison Jacoby-Fries, who stated the youth are offered outdoor time daily
but sometimes the youth choose not to go out because of other activities they are doing inside at the time they are offered. Sometimes
youth will ask to go outside at other times, and staff are not always available to take them outside at the requested time.
- All the children reported being provided enough food to eat, to include receiving daily snacks. Some reported wanting more variety with food
options. One youth at the Downtown Shelter Program reported having dental challenges that limited her from eating certain foods (hard
textured) She expressed wanting more options of softer foods to eat. The Licensing Coordinators followed up with the Program Manager
who stated she would follow up with the nutritionist. Prior to the interview there had been follow up by the program's medical staff regarding
this issue.
- The children all reported their hygiene needs were being met by the program.
- All the children but two reported feeling safe at the programs where they were residing, to include foster homes. Two Sage Youth reported
not feeling safe in the program, when asked why they didn't feel safe they stated:
o "Most of the time I feel safe, I have heard from other youth about other clients going into bedrooms while someone is asleep." (This
has not been this person's experience, and she stated she has expressed these concerns with staff.) It is a program rule that
bedroom doors cannot be locked when youth are in their bedrooms.
o "I do not feel safe here, and I have told staff how I feel. People hit each other a lot, three girls left this month for hitting another youth
and one youth hit a staff." She also shared that a youth had chocked a staff. She shared a youth was in a rolling chair and was
asked by staff to get out of the chair. The youth refused to move, and the staff pulled the youth by her ponytail into another room and
dumped the youth out of the chair. This was called into the Child Abuse Hotline on November 15, 2022, by the Licensing
Coordinator. Prior to leaving the Sage Program, the Licensing Coordinators, spoke with the Program Director, Kelli Doolittle
regarding this concern.
Observations: While conducting the onsite inspection at the programs, children and staff were observed. The children that were observed appeared
to be at ease and comfortable while residing in the programs. The facilities were observed to be well maintained, with minimal repair needs as
stated below in the report.
Agency Strengths:
The following strengths were identified by Morrison Leadership:
6
- "The agency has increased wages for their employees.
- The staff, the team, and leaders want to expand their programs, and are committed to their jobs.
- Youth feeling that the staff care about them.
- Longevity of Leadership.
- The agency has a commitment to quality of care.
- March 2022, is the 75th Anniversary for Morrison Family Services."
Individual Program Strengths: Identified by program managers.
- Foster Care Program (to include Planned Respite Care):
o "TFC & Behavior Health (BH)-TFC & PCRC: The youth, though a small number, were supported and maintained in their placements
throughout the Pandemic. Resource parent supports also continued with many services provided remotely. When school resumed,
resource parent responsibilities for schooling and educational supports was eased. While the Program experienced some staff turnover,
new Foster Care staff were hired and oriented to the Program. The Program received Workforce Stabilization Grant funds to help bolster
staff shortages and support the recruitment and retention of resource homes. The Behavioral Health Therapeutic Foster Care pilot
project was initiated to integrate Behavior Rehabilitation Services (BRS) therapeutic foster care services with intensive mental health
treatment. BH-TFC is a state-wide project in which Morrison is one of seven agencies providing this new service. A community-based
mental health therapist was hired to support the mental health needs of BH-TFC and TFC youth. The program also added a new
position, a Business Manager, to support the foster care programs with budget plans, donation support and tracking, and grant reporting.
During this time, the respite program maintained its utilization of respite beds. Since COVID-19 restrictions have lifted, more respite
placements have occurred."
- Counterpoint:
o "Counterpoint Day Treatment and Proctor Care (CPDT) programs have a long history of successful treatment outcomes. The length
of service for CPDT proctor parents is longer than average due to training, peer supports, frequent respite, and daily support of the
day treatment program staff. CPDT management staff are long term Morrison employees. The Program has had a recent increase in
referrals from ODHS and local school districts for day treatment services only. Flexible service opportunities are offered, such as
serving a ODHS referred youth in day treatment and placing the youth in an OYA certified proctor home. The Program also has the
opportunity to add outpatient sexual offense treatment services within the existing OYA contract. There is also an Outpatient
Substance Use Disorder (SUD) Treatment Services component within CPDT and CPDT has qualified Certified Drug and Alcohol
Counselor (CADC) staff. Counterpoint Day Treatment continued services throughout the Pandemic despite stay-at-home orders and
the need for intensive infection control protocols. Youth were transported to the Center daily and a school day was provided
remotely. BRS services and treatment services continued in person or remotely."
- SAGE:
o "SAGE has a very strong foundation of trauma informed care that guides all treatment and interpersonal activities at SAGE.
7
o SAGE is fortunate to have adequate and sustainable funding from OHA. This funding allows us the ability to provide a safe, comfortable,
welcoming, and therapeutic environment for youth. Recent rate increases have helped with providing competitive salaries.
o Leadership positions at SAGE have very low turnover which contributes significantly to program stability and quality
o Morrison has invested in Joint Commission Accreditation and is pursuing Sanctuary Certification which both add an additional layer of
quality to the program.
o The ability to provide long-term treatment allows us to really form relationships with the youth, provide high quality mental health and
substance use treatment, and increases their chance of a successful discharge."
- Residential Care Program Update-Long Term Group Home (LGTH), and Downtown Shelter Program (ORR):
o '"The Downtown Shelter and Long-Term Group Home youth reported overall satisfaction with the program and that they received
support from the program during their stay.
o Increased training for supervisors on relationship building and importance of supervision. Providing additional training for all
supervisors to support them in setting expectations, clarifying roles, and agency requirements. This is being done to increase staff
retention and satisfaction.
o Programs are continuing to provide the Child and Youth Care Certification Board training to all direct care staff. Currently most of the
direct care staff have gone through the training and certification process.
o Staff have been cross-trained in different areas and programs, allowing for back-up coverage and consistent program operations
when there is a fast-paced work environment and staff turnover. Staff have successfully supported multiple programs.
o Programs have created a welcoming environment for youth by integrating more cultural appropriated resources in their education,
recreational activities, food, communities' groups, and mental health resources. Recreational spaces for youth such as our second-
floor gym, activity and peace room have allowed youth to find a safe and healthy method for releasing frustrations. Youth have
benefited from recreational activities such as Soccer coaching, Educational outings, Gardening classes, Art & Music classes, and
talent shows.
o Programs adapted to the challenges of the COVID-19 Pandemic with flexibility and creative approaches; implemented and followed
multiple infection control procedures."

program_challenges:
Individual challenges identified by program managers.
- Foster Care Program (to include Planned Respite Care):
o "Significant program challenges were related to the impact of COVID-19. Youth were schooled at home placing additional
responsibility on foster parents. Foster home recruitment slowed down significantly due to COVID-19 restrictions slowing program
growth and development. Morrison's BH-TFC pilot started in May 2021 and a community-based mental health therapist was added to
the foster care team. Unfortunately, the therapist resigned after 6 months and rehiring for the position took nearly 9 months. Youth
were transferred to the Morrison Outpatient Community-Based Program during the interim for continuity of care and treatment.
Resource parents also decided to close their homes and discontinue their foster care certifications, some due to COVID-19 and
others due to life changes within their families and households. The reduction of resource homes and the current challenges of
recruiting new homes remains difficult."
- Counterpoint:
8
o "Recruitment of proctor parents who are qualified to serve this high-needs population is difficult. Open staffing positions are also
increasingly difficult to fill due to fewer people looking for work and the need for professional staff in highly specialized fields i.e.
addictions treatment and sexual offense treatment. At the present time OYA proctor home beds are unfilled. Another challenge is the
cost of required staff training. Training often requires supplemental staffing to cover day treatment programming while the on-going
staff are in training. Facilities upkeep takes longer due to the lack of contractors or the lack of availability. Improvements needed can
be prohibitive due to increasing building costs and lack of budget availability. Vandalism or theft of agency vehicles have caused
increased spending on repairs and increased attention to security concerns. Lack of diverse service providers limits client
populations that can be referred. At the present time the CPDT staff are English-speaking only. Meal services are dependent upon
the availability of school district dining services and their capacity to deliver daily food. The need to purchase food for clients during
times when school is not in session has increased and the lack of cooking facilities onsite limits options."
- SAGE:
o "Staffing has been a challenge due to COVID and SAGE funding. SAGE was not eligible for several residential rate increases that
were given to BRS programs and other mental health residential programs. Other community programs increased salaries and
SAGE was unable to increase salaries until very recently.
o High acuity youth with frequent escalations led to milieu instability, staff injuries, and property destruction on a few occasions.
o Many recent referrals are youth with significant histories of aggression. SB 710, increased investigations, and the impact on staff
involved in highly aggressive incidents has influenced our willingness to take these youth."
- Residential Care Program Update-Long Term Group Home and Downtown Shelter Program (ORR):
o "Throughout the past two years Morrison has continued to experience significant challenges and delays in hiring staff for
the Downtown Shelter and LTGH programs. Challenges have occurred in the following areas: recruiting and hiring direct
service and management staff with the qualifications necessary for the vacant positions.
o Staff resignations and staff turnover have put pressure on service delivery and program operations.
o The COVID-19 pandemic impacted the programs as more staff were out sick for longer periods of time and programs
were required to manage housing youth in isolation and quarantine floors. Working in residential settings became less
desirable.
o Programs received a new population of youth that they were not quite prepared to receive due to language barriers and
behavioral challenges.
o Higher acuity youth with behavioral and mental health challenges.
o Programs were not at capacity due to staff shortages."

changes_in_last_two_years:
Individual program changes in the last two years identified by program managers.
- Foster Care Program (to include Planned Respite Care):
9
o "Significant programmatic changes occurred in response to COVID-19 precautions and protocols altering the way that the Program
interacted with youth, resource parents, and the community. Masking and social distancing continued and working from home
became the norm. The program offered both telehealth services, virtual home visits, and in-person contacts. Foster youth contact
was maintained throughout the Pandemic. In May 2021, the Morrison Foster Care Program began piloting the BH-TFC program and
hired a community base mental health therapist to support the intensive mental health needs of youth. In September, 2021 Morrison
foster care programs made the policy decision to prohibit physical restraint of foster children. Program managers have been
responding to new SB 710 reporting."
- Counterpoint:
o "Counterpoint expanded its program space after the closure of Breakthrough Day Treatment on June 30, 2022. The addition of 2
proctor homes has also increased the available beds for day treatment and proctor service from 9 to 14 youth. ODHS and local
school district day contracts for day treatment only services have become more common and frequent. Counterpoint Outpatient
closed last year and the Counterpoint Day Treatment Program has accepted referrals for outpatient services, too. OYA is contracting
with Morrison to provide these services. The Rotary Youth Center was completed and was extremely beneficial for the youth through
the pandemic when there were few options for public activities. Because of the continuous vandalism and theft of the day treatment
vehicles, they are now parked offsite at the Mt Scott residential location. It is an inconvenience to store and retrieve vehicles off-site,
but there are fewer security issues. A new minivan was purchased during the new car shortage. This vehicle replaces the usage of
1 of our 12 passenger vans and allows us to transport small groups of youth in a more reasonably sized vehicle."
- SAGE:
o "Implementation of new programming assuring that youth have more consistent and more private contact with family and supports.
o Implementation of staff training, new program policy, and client education and support regarding racial and cultural diversity.
o Expanded courtyard garden area, partnered with Portland Public Schools to develop an integrated earth science program for youth in
care."
- Residential Care Program Update-Long Term Group Home and Downtown Shelter Program:
o "New Division Director started in May 2021.
o Shelter and Long-Term Group Home have not been at capacity for the past two years.
o DT Shelter Program started accepting female youth again in June 2022.
o New positions were created to bring full focus and attention to hiring and supporting the Milieu components of the programs."

excerpt: (3)(g) Approval from BCU

excerpt:
Documents as indicated on the form titled
“Renewal Licensing Required Documents”

excerpt:
All required policies and procedures as
identified in the “Umbrella Rules”

excerpt:
All required policies and procedures as
identified in “Agency Type Specific Rules”

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

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

excerpt:
Buildings are smoke free,
clean and in good repair Corrective Action