15: Announced Visit: Compliance Issues Copy

Facility Type: 730/733 (Group Home)

Investigation Findings
This Facility Evaluation Report is a continuation of the Non-Compliance Conference Summary report dated 9/22/15 where Community Care Licensing (CCL) and Department of Children and Family Services (DCFS) met with Facility to address compliance issues within their facilities. This report outlines the Plan of Corrections CCL discussed during the meeting held on 9/22/15. The POCs are required in order to bring Facility into compliance with Title 22 Regulations.

CCL staff discussed concerns regarding medication errors. A client’s medication was missed due to pharmacy delivering medication late, medication was left in the bubble pack, and staff packed the wrong medication. Facility agreed to retrain staff on medication procedures and provide CCL with a copy of the medication procedures. CCL advised to submit a written narrative explaining how Facility will ensure medication errors do not reoccur. Explain the process with delivering medication and include what action is being taken against staff when they make medication errors. Review program statement/medication policy to verify whether it is correct. Submit a copy of the medication policy/procedure to CCL for review. Also, submit verification staff has been retrained on medication procedures.

CCL discussed concerns regarding Facility not following their Plan of Operation. Staff are not following body check procedures and documenting injuries accordingly. Facility admitted staff are not following established protocols. However, they will retrain staff on the body check procedure and ensure staff are documenting all injuries. Proof of retraining to be submitted to CCL.

CCL discussed concerns regarding staff not providing adequate care and supervision. When a client was exhibiting suicidal and cutting behaviors, staff failed to pick up the client from school in a timely manner. CCL reminded Facility that there should be staff available to pick up clients from school when needed. Facility agreed to pick up clients when school staff contacts them. Staff must ensure the appropriate contact numbers are provided to school personnel. Facility to submit a narrative verifying this will happen.

CCL discussed concerns regarding Non-Minor Dependents remaining in the program past their 19th birthday. CCL advised Facility to establish protocols to ensure the client has transitioned out of the program prior to the 19th birthday. These protocols to be submitted to CCL as part of this POC. CCL explained that we will approve age exceptions in some cases, in accordance with regulations. Facility agreed and will work closely in the transition of the client (with the supervising social worker or assistant regional manager, if necessary).

CCL discussed concerns regarding clients AWOLing from the facility. Per Facility, AWOLs are occurring when the clients are at school and during the summer while at the facility. Facility stated they have various activities available for the clients. CCL advised to tighten up the AWOL policy by having a dialogue with the clients to find out why they are AWOLing and what they can do to prevent them from AWOLing. Also, staff did not perform an appropriate follow-up with a client upon her return to the facility from AWOL. CCL advised Facility to meet with the client upon their return to find out why and how they AWOLed, if unknown. Also, Facility must develop an AWOL Plan specific to a client who has an AWOL history as required in the regulations. CCL advised to submit a written narrative explaining what Facility is doing to decrease or eliminate the excessive number of AWOLs. In your discussion, talk about how Facility now investigates how clients AWOL & return from AWOL. Facility has implemented a new protocol to address the clients’ AWOL upon their return. CCL advised to send a copy of the new procedure to CCL for review.

CCL reminded Facility to ensure the clients’ Needs and Services Plans and Individual Family Service Plans are current and placed in the client files. They also should be signed by the child’s representative prior to implementation.

Facility informed CCL that registry staff are utilized at the regional center homes only. The staff are trained by the agency and the group home prior to working. These staff also meet all of the other personnel requirements before being left alone with clients. Facility to provide CCL with narrative regarding the use of registry staff and how they must meet personnel requirements.

Facility informed CCL there are multiple security cameras surrounding the outside of the facility. CCL requested to know all locations of the cameras and a reason for having them. CCL also discussed the waiver process with Facility, if they decide to install cameras inside the facility.

CCL discussed concerns regarding security guards performing child care worker duties. A security guard was involved in an incident by intervening and disciplining a client. Facility agreed that security guards should not interfere with incidents involving clients nor discipline the clients. Facility informed CCL that security guards work on campus at night only. CCL discussed that security guards must obtain a criminal record clearance. Facility will ensure the security guards obtain a criminal record clearance and send their work schedule and job duties to CCL for review for the POC in this regard.

CCL advised Facility to retrain staff on Unusual Incident Report writing. Incident reports are missing information and incomplete. Also, addendums are not being submitted for serious incidents. CCL advised Facility to ensure staff are writing thorough incident reports and following up with addendums, if applicable. Facility will submit verification to CCL that staff have been retrained on completing unusual incident reports.

CCL advised Facility to follow up with CCL regarding meeting with the various regional centers to discuss the facility’s responsibility to ensure the child’s health and safety is top priority in medical emergencies instead of waiting for the biological parent’s approval to seek emergency treatment.

CCL advised Facility to follow up with CCL regarding the next Quarterly Meeting with the Sheriff Department in regards to improving the AWOL problem.

This report is being delivered on 10/5/15 for review and signature. However, these Plans of Corrections must be submitted to CCL within 30 days or by November 5, 2015.

Note: The Compliance Plan will be ready for execution within 30 days.


Facility Report


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