STARR Resiliency Agency

Five children interviewed stated that a caregiver threatened that a child/children could not eat dinner unless the child/children took a shower.

Follow up was not provided by the original compliance of 7/12/2024.

The follow up was not provided by the original compliance date of 7/12/2024.

Follow up was not provided by the original compliance of 7/12/2024.

Follow up was not provided by the original compliance of 7/12/2024.

Follow up was not provided by the original compliance of 7/12/2024.

A staff member of the operation did not have a pre-employment drug screening.

The operation's administrator stated the records for EBI written test gets shredded and that the operation does not keep record of them, therefore, there is no record showing the staff member took a written test.

It took the operation eight days to provide requested documentation.

The incident report was not consistent with the interviews of staff regarding the incident that occurred.

A child's room was searched, however, there was no documentation completed.

A child in care with sex trafficking history was allowed outside without supervision. The service plan specifically documents the child requires "visual and auditory" supervision while at the operation. Additionally, it documents the child has a "history as a victim of sex trafficking", which "makes her more susceptible to elopement and unsafe sexual activities."

The documentation did not include the time and date when the children's parents and the relevant law enforcement agency were notified. Furthermore, there was no record of the names of the individuals contacted.

The parent of a child with sex trafficking history was not made aware immediately of the child's unauthorized absence. The child eloped at 6:19PM and the parent was not notified until 7:31PM.

The information documented in the serious incident report did not align with the information gathered from interviews with children and staff.

A Direct Care Staff is currently working at the operation without an approved background check. The staff's background check was ran on 7.26.24. The staff was present during an incident on 7.27.24. The background check has not been completed as of 8.15.24. Additionally, it was found the staff worked 8.11.24 and is scheduled for 8.16.24.

Background checks for two employees were not conducted by the operation.

The medication log for a child is missing the medication dosage and time administered.

The operation was not able to provide the emergency drill records during the inspection.

Two out Three childrens records reviewed were missing several policy components to include the emergency behavior interventions.

The discharge summary record for a child was not filled out. It was also missing singnatures for all parties that should of been involved.

All four incident Reports reviewed did not include the telephone number of the operation.

Three children's records did not have a parent orientation.

Documentation was requested 3 times within a 3-week period from the operation.

RCI had to request documents multiple times within a three-week period before receiving documents.

The operation failed to submit a corrective action plan addressing compliance for not submitting records to RCCR until five days after the original request date, despite RCCR sending multiple reminders.

On 11/03/2023, during the in-person investigation records were requested but told that they would be provided via email and sent to the RCCL Inspector. On 11/15/2023, an email was sent to the operation requesting records and that they needed by the end of the day on 11/17/2023. On 11/16/2023, due to not receiving a reply from my previous document request a reminder email was sent requesting that the document be provided by the end of the day on 11/17/2023. On 11/17/2023, another email was sent to the operation stating that documents had not yet been received and for them to be provided. On 11/20/2023, documents were provided by the operation.

Records/Documentation was requested 2 times by an investigator and 1 time by a licensing supervisor. It was initially requested on the October 27th, and it was not sent until November 14th at approximately 10:51 PM.

It is found after the review of the incident report that the incident occurred on 08/08/23 and the child in care left the operation at 7:27pm. It was reported to licensing on 8/09/23 at 12:01pm. This reporting to licensing is not in the required time frame.

A child in care who was admitted to the operation despite being outside of the licensed age range.

Records were requested on 7/3, 8/2, 8/3, and 8/4. Partial records were received on 8/3. An inspection to the operation was conducted on 8/18 where 4 service plans were obtained; however incident reports being requested were not in the child's files. Licensing was informed that incident reports may have been scanned into the operation's electronic system. Those incident reports were requested to be sent to Licensing by end of the day on 8/18. The incident reports were never received.

Multiple children in care reported staff threatening to send children to a "mental hospital" even when there were times where a child's behaviors did not warrant such hospitalization.

Insulin was found unsecured in the refridgerator.

This operation did not report the 1st Quarter (January-March) EBI numbers as required despite several reminders by the RCCR Inspector via email to the operation on 4/18/23, 5/1/23 and 5/2/23.

At the time the case was called in, the operation had 5 girls in placement and was only licensed to take boys. The operation now has a new permit allowing placement of both boys and girls.