State of Michigan DEPARTMENT OF HEALTH AND HUMAN SERVICES

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RICK SNYDER GOVERNOR June 27, 2018 State of Michigan DEPARTMENT OF HEALTH AND HUMAN SERVICES DIVISION OF CHILD WELFARE LICENSING NICK LYON DIRECTOR Jennifer Santer Teaching Family Homes of Upper

Santer, Attached is the Interim Inspection Report for the above referenced facility completed on 06/19/18.

1 RICK SNYDER GOVERNOR June 27, 2018 State of Michigan DEPARTMENT OF HEALTH AND HUMAN SERVICES DIVISION OF CHILD WELFARE LICENSING NICK LYON DIRECTOR Jennifer Santer Teaching Family Homes of Upper Michigan 1000 Silver Creek Road Marquette, MI RE: License #: CI Lakes Area Teach Family Home 7820 State Hwy M-123 Newberry, MI Dear Ms. Santer, Attached is the Interim Inspection Report for the above referenced facility completed on 06/19/18. Due to the violations of applicable licensing rules, sections of the contract and Implementation, Sustainability, and Exit Plan, (ISEP) requirements, a written corrective action plan is required. It should be noted that violations of any licensing rules are also violations of the ISEP and your contract. The corrective action plan is due 15 days from the date of this letter and must include the following: How compliance with each citation will be achieved. Who is directly responsible for implementing the corrective action for each licensing statute and rule or section of the contract or ISEP citation. Specific time frames for each citation as to when the correction will be completed or implemented. How continuing compliance will be maintained once compliance is achieved. Repeat violations require an explanation as to why the previous corrective action plan failed to prevent repeat violations of the rules and policy. The signature of the responsible party and a date. If you fail to submit an acceptable corrective action plan, disciplinary action may result. P.O. BOX LANSING, MICHIGAN (517)

2 . Please review the enclosed documentation for accuracy and contact me with any questions. In the event that I am not available and you need to speak to someone immediately, please contact Claudia Triestram, Area Manager, at Sincerely, Doug Turrill, Licensing Consultant MDHHS\Division of Child Welfare Licensing Suite S. Elmwood Traverse City, MI (231) enclosure 2

3 MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES DIVISION OF CHILD WELFARE LICENSING INTERIM INSPECTION REPORT I. IDENTIFYING INFORMATION License #: Licensee Name: Licensee Address: CI Teaching Family Homes of Upper Michigan 1000 Silver Creek Road Marquette, MI Licensee Telephone #: (906) Administrator/Licensee Designee: Name of Facility: Roxanne Daust, Designee Lakes Area Teach Family Home Facility Address: 7820 State Hwy M-123 Newberry, MI Facility Telephone #: (906) Original Issuance Date: 09/01/1990 CMH Funded Facility Yes Program Type Setting Gender Capacity From Age Thru Age Behavior Mgt. Room Location Treatment Open MALE NO NEWBERRY

4 II. METHODS OF INSPECTION Date of On-site Inspection: June 12, 13, 19, 2018 Date of Fire Inspection: January 27, 2017, A Rating Date of Environmental/Health Inspection: January 25, 2017, A Rating Total No. of Records No. of Records Reviewed No. of current residents (secure-treatment) NA NA No. of current residents (secure-shortterm) NA NA No. of current residents (open-treatment) 7 3 No. of current residents (open-shortterm) 0 0 No. who have left the program since the last inspection NA NA (secure-treatment) No. who have left the program since the last inspection NA NA (secure-shortterm) No. who have left the program since the last inspection NA NA (open-treatment) No. who have left the program since the last inspection 8 2 (open-shortterm) No. of Facility Restraints since the last inspection 10 4 No. of Facility Seclusions since the last inspection NA NA No. of Records No. of current employees who have worked at the facility for: Reviewed More than a year 11 4 Less than a year 1 1 No. Of persons Interviewed: Direct Care Staff 3 Supervisory Staff 1 Administrators 1 Residents 3

5 The following required records were on file and available for review: Program Statement Yes No NA Program Policies Yes No NA Staff Training Records Yes No NA Income/Expenditure for current year, including most recent Financial audit Yes No NA Staff TB Screening Records Yes No NA Staff to Resident Ratio Yes No NA Posted Notice: Criminal History Check for employees and volunteers Yes No NA Criminal History and Child Protection Registry Checks for employees and volunteers Yes No NA Volunteer Supervision Policy Yes No NA Behavior Management Room Log Yes No NA Meal Menus Yes No NA 3

6 III. DESCRIPTION OF FINDINGS 1.) The facility is in compliance with all applicable rules and statutes except for the following: R Institutions not detention institutions or shelter care institutions; initial treatment plan. (3) The initial treatment plan shall include all of the following: (f) Staff techniques for achieving the resident s treatment goals, including a specific behavior management plan. The plan shall be designed to minimize seclusion and restraint and include a continuum of responses to problem behaviors. Three files and 7 service plans were reviewed. Two files contained Initial Treatment Plans (ITP) that did not document a specific behavior management plan for the residents. The ITP s were dated 03/05/18 to 04/03/18 and 09/06/17 to 09/27/17. R Employee records. An institution shall maintain employee records for each employee and shall include documentation of all of the following information prior to employment or at the time specified in this rule: (i) Documentation from the Michigan department of human services, the equivalent state or Canadian provincial agency, or equivalent agency in the country where the person usually resides, that the person has not been determined to be a perpetrator of child abuse or child neglect. The documentation shall be completed not more than 30 days prior to the start of employment and every 12 months thereafter. 1

7 Five employee files were reviewed. Two files contained Central Registry Clearances that had expired. One file contained clearances that were dated 04/05/17 and 05/05/18. The 05/05/18 clearance had occurred more than 12 months from the previous clearance. The second file documented clearances dated 04/05/17 and 04/24/18. The 04/24/18 clearance occurred more than 12 months from the previous clearance. This is a second repeat violation. The original violation was established during the Interim Inspection completed on 06/01/16 and an acceptable corrective action plan was received on 06/30/16. A repeat violation was established during the Renewal Inspection completed on 04/18/17 and an acceptable corrective action plan was received on 05/02/17. R Tuberculosis screening for employees and volunteers. The licensee shall document, prior to employment, that each employee and volunteer who has contact with residents 4 or more hours per week for more than 2 consecutive weeks is free from communicable tuberculosis. Freedom from communicable tuberculosis shall be verified within the 1-year period before employment and shall be verified every 1 year after the last verification or prior to the expiration of the current verification. Five employee files were reviewed. One file documented that the employee had a TB test on 02/02/18. The file did not contain a TB test for the year R Social service worker; qualifications. A social service worker, at the time of appointment to the position, shall possess a bachelor's degree with a major in a human behavioral science from an accredited college or university or another major with 25% of credits in human behavioral sciences. 2

8 Five employee files were reviewed. The agency Consultant position requires that the person in the position meets the requirements of Social Service Worker as described under the rule. The employee who currently holds the position of Consultant does not have bachelor s degree from an accredited college or university. R Grievance procedures. (1) An agency shall have and follow a written grievance handling procedure for residents and their families. All of the following apply: (a) The policy shall be provided to residents, their families, and referring sources prior to or at admission. Three resident files and 7 service plans were reviewed. One file lacked documentation that the resident s parent had received the agency grievance policy. R Dental Care. (2) A dental examination within 12 months prior to admission shall be documented or there shall be an examination not later than 90 calendar days following admission. Three files and 7 service plans were reviewed. One file did not document that the resident had a dental examination within 12 months prior to admission or an examination not later than 90 calendar days following admission. R Institutions not detention institutions or shelter care institutions; updated treatment plan. (1) The social service worker shall complete, sign, and date an updated treatment plan for each resident at least once every 90- calendar days following the initial treatment plan. Three files and 7 service plans were reviewed. One file contained an UTP that was due on 12/26/17 and the plan was completed on 12/27/17. The plan was 1 day late. R Institutions not detention institutions or shelter care institutions; updated treatment plan. (2) The updated treatment plan developed by the social worker shall document input from the resident, the resident's parents, 3

9 direct care staff, and the referral source, unless documented as inappropriate. Three files and 7 service plans were reviewed. Two files contained UTP s that were not signed by the parent. One file contained a UTP dated 12/26/17 was not signed by the parent. A second file contained a UTP dated 03/19/18 that was not signed by the parent. This is a second repeat violation. The original violation was established during the Interim Inspection completed on 06/01/16 and an acceptable corrective action plan was received on 06/30/16. A repeat violation was established during the Renewal Inspection completed on 04/18/17 and an acceptable corrective action was received on 05/02/17. R Institutions not detention institutions or shelter care institutions; updated treatment plan. (3) The updated treatment plan shall include all of the following information: (c) Changes in the treatment plan, including new problems and new goals to remedy the problems. Indicators of goal achievement and time frames for achievement shall be specified along with a specific behavior management plan designed to minimize seclusion and restraint and that includes a continuum of responses to problem behaviors. Three files and 7 service plans were reviewed. Two files contained UTP s that did not document a specific behavior management plan. One file contained UTP s dated 09/28/17 to 12/26/17 and 12/27/17 to 03/19/17 that did not contain a behavior management plan. A second file contained UTP s dated 07/22/17 to 10/09/17, 10/10/17 to 01/07/18, and 01/08/18 to 04/02/18 that did not contain a specific behavior management plan. R Institutions not detention institutions or shelter care institutions; updated treatment plan. (5) The social service supervisor shall approve, countersign, and date the updated treatment plan. 4

10 Three files and 7 service plans were reviewed. Two files contained UTP s that were not signed by the social service supervisor. One file contained UTP s dated 04/02/18 and 01/07/18 that were not signed by the supervisor. A second file contained UTP s dated 12/26/17 and 03/19/18 that were not signed by the supervisor. This is a repeat violation. The original violation was established during the Renewal Inspection completed on 04/18/17 and an acceptable corrective action plan was received on 05/02/17. R Dental Care (1) A licensee shall provide for and document dental examinations and treatment for each resident 3 years of age and older. (3) Reexamination shall be provided at least every 14 months unless greater frequency is indicated. Three files and 7 service plans were reviewed. One file documented that the last dental exam the resident received was on 06/01/16. A 14 month dental exam was due on 10/01/17. The dental exam is overdue. R R Institutions not detention institutions or shelter care institutions; updated treatment plan (3) The updated treatment plan shall include all of the following information: (c) Changes in the treatment plan, including new problems and new goals to remedy the problems. Indicators of goal achievement and time frames for achievement shall be specified along with a specific behavior management plan designed to minimize seclusion and restraint and that includes a continuum of responses to problem behaviors. Three files and 7 service plans were reviewed. One file contained UTP s dated 10/10/17 to 01/07/18 and 01/08/18 to 04/02/18 that did not specify action steps that the agency was taking to assist the resident toward successful completion of goals. 2.) Any violation listed in section 1 is also an ISEP violation. Please note that there are additional ISEP requirements that may not be included in section 1. The facility is in compliance will all additional ISEP requirements. 3.) Any violation listed in section 1 is also a DHS Contract/Policy violation. Please note that there are additional DHS Contract/Policy requirements that may not be 5

11 included in section 1. The facility is in compliance will all additional DHS Contract/Policy requirements except for the following: JR Psychotropic Medication - Informed Consent The facility staff must obtain informed consent for each psychotropic medication prescribed to a youth. An informed consent is consent for treatment provided after an explanation from the prescribing clinician to the consenting party of the proposed treatment, expected outcomes, side effects, and risks. The DHS-1643, Psychotropic Medication Informed Consent, must be used to document the discussion between the prescribing clinician and the consenting party. Three files and 7 service plans were reviewed. One file lacked documentation that informed consent was obtained for the psychotropic medication the resident was taking. IV. TECHNICAL ASSISTANCE The facility was offered technical assistance in the following areas. R Bedding and linen. Rule 138. (3) All bedding shall be in good repair and shall be cleaned and sanitized before being used by another person. This Consultant viewed the facility and resident s bedrooms. On one resident bed there was a comforter that was torn on the corner and the comforter stuffing material was hanging out. Technical assistance was provided. V. CONSULTATION Consultation was not requested or required at this time. VI. EVALUATION OF RENEWAL PERIOD There were no substantiated incidents of maltreatment in care during this licensing period. There were no incidents of substantiated child abuse and/or neglect during this licensing period. There were no incidents of substantiated corporal punishment during this licensing period. The facility has submitted 2 acceptable corrective action plans not related to 6

12 maltreatment during this licensing period. The agency submitted 2 acceptable corrective action plans during the licensing period. On 05/02/17 the agency submitted a corrective action plan in response to those rule and policy violations established during the Renewal Inspection completed on 04/18/17. The agency submitted a second corrective action plan on 06/04/18 in response to a rule violation established during special investigation #2018C What follows is a summary of the agency corrective action plans and their effectiveness in preventing repeat violations of the rules and policy. Renewal Inspection: R Employee Records. The current Interim Inspection established a second repeat violation of the rule (see above). The past two corrective action plans have not been successful in preventing repeat violations of the rule. R Employee Records. The current inspection established that the agency CAP was successful in preventing a repeat violation of the rule. Of the employee files reviewed each documented that employee performance evaluations were completed in the time frames specified by the rule. R (2) Institutions, not detention institutions or shelter care institutions: updated treatment plan. The current inspection established a second repeat violation of the rule, (see above). Two service plans were not signed by the parent. R (3) (b). Institutions, not detention institutions or shelter care institutions: updated treatment plan. The current inspection established, of the service plans reviewed, that each documented progress towards goals. The agency CAP was successful in preventing a repeat violation of the rule. R (5) Institutions, not detention institutions or shelter care institutions: updated treatment plan. The current inspection established a repeat violation of the rule, (see above). Four service plans were not signed by the supervisor. Special Investigation #2018C The agency submitted a CAP on 06/04/18 in response to a violation of R Chief Administrator, responsibilities. The agency had been found to be in violation of the rule as the acting Chief Administrator lacked one of the requirements for the position. DCWL granted an exception to the rule and the agency submitted an acceptable CAP. At the time of the inspection a very short period of time had lapsed since the CAP was submitted. Additional evaluation will occur at the time of the renewal inspection in

13 VII. RECOMMENDATION Based on inspection findings the facility is not in compliance with all applicable licensing statutes and rules and/or ISEP requirements and/or contract/policy. Upon receipt of an acceptable corrective action plan, it is recommended that the facility continue on their regular license. June 25, 2018 Doulas Turrill Date Licensing Consultant Approved By: June 27, 2018 Claudia Triestram Date Area Manager 8

CI C Wolverine Secure Treatment Center

CI C Wolverine Secure Treatment Center RICK SNYDER GOVERNOR STATE OF MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES DIVISION OF CHILD WELFARE LICENSING LANSING NICK LYON DIRECTOR June 7, 2016 Troy Mitchell Wolverine Human Services 15100 Mack