Her Heart Can

One of two caregiver's file reviewed did not have documentation showing the pre-emoloymeent screening assessment.

One of two caregiver files reviewed did not have an affidavit on file.

There has not been a full-time administrator at the operation two of four weeks based on timecards reviewed.

One of two caregiver files reviewed did not have documentation of the pre-employment affidavit on file.

One of two caregiver's file did not the results of the drug testing.

The operation failed to notify RCCR of the unauthorized absence of two youth in care.

There has not been a full time administrator at the operation for the last two of four weeks.

The operation was not able to provide verifiable proof that the administrator is working full time at the operation.

The PLSP file reviewed did not have documentation showing they meet the qualifications requirements.

In the two staff file reviewed both had only one of the previous employers contacted to verify employment.

One of the staff file reviewed during the inspection did not include the required two references.

Based on the weekly schedule and timecards, the LCCA is not a full-time employee of the operation.

The named treatment director does not have documentation on file showing they meet the specific educational/professional qualifications.

During Walkthrough of the operation, it was discovered that the menu was not completely filled out and substitutions were not offered (Standard 1703 b).

There are 3 runaway reports on the unauthorized absence log that indicate children were away from the operation more than 6 hours. The reports were not received timely and or documentation of the unauthorize absence log is incomplete.

A child in care was arrested from school. This was not reported.

In one of two staff records reviewed, dates are missing from training documentation, unable to verify if pretraining was completed within 90 days of beginning job duties.

A caregiver is showing active in the operation people list, the caregiver has not been employed with the operation for twenty days.

During the outside walk through, sharp items and sharp glass was observed on the ground, near the barn.

The unauthorized absence log did not include the time the absence was discovered by the staff on two of two occasions, the hotline report number for one of two occasions nor information on the length of time the youth was missing or if the youth returned on two of two occasions.

One of two staff records reviewed, did not detail how the staff was qualified for their role at the operation.

The operation has allowed two individuals access to children in care without received the eligibility notification.

A serious incident report was not completed for a medical event that occured at the operation.

During today inspection, the well house was in need of maintenance.

The operation has admitted a child in care that does not meet the operation's admission policy.

At the time of the inspection, the operation did not have insurance for the vehicle being used to transport the children in care.

During today inspection, several items were in need of maintenance.

The written EBI policies did not meet standard 748.2801(2)(A), 748.2901(a)(2) or (B), 748.113(a)(v), (viii), (ix) or (6).

The suicide postvention written plan did not include the required items in 748.125(g)(B)(i) (I-VI).

The diagram did not include the designated location in the case of fire. The diagrams were fixed during the inspection.

Bedroom #4 did not have direct access to a bathroom without having to cross activity spaces.

The tobacco policy did not address smoking in the vehicle.

Several policies violated the requirements of 748.303 and 748.313. Further there were no policies for record storage in regards to SIRs.

Operation is getting licensed for girls only, and biological girls that are currently pregnant, policies did not state this. The application indicates children ages 14-17 are admitted, however the policy states ages 7-17.

The policy did not address any of the standards regarding children under the age of 10.

A trailer was observed in the back yard with nails sticking up that could become hazardous to youth in care.

There was a smoke detector outside of one of the bedroom.

One bathroom sink had a crack in the bowl that was leaking in the under cabinet.

The water quality test was not done for the private water supply.

There was no policy that included this information.

Conflict of interest policies did not meet the requirements of 748.107(1) and (2).