Tshepang Center Residential Treatment Center, LLC

During a review of the child's service plan, it was found that the plan did not include the following: cultural identity needs and plans, instructions to the caregiver about the child's trauma history or triggers, nor does it include methods of responding that increase trust, help them feel safe, and adapt to their environment. The service plan also does not include a mock safety plan or caregiver inclusion. Finally, the plan does not have all treatment services provided.

During a review of the policies that the operation submitted there was not and fiscal plan or documentation to reserve funds or available credit for to at least equal cost for three months. Furthermore, there was no estimated 12-month budget of income or expense.

During a review of the service plan it does not identfy the normalcy decision maker in the team.

During a review of the policies, it was determined that the policy manual identifies the CEO as a controlling person but does identify all board as a controlling person...

Out of three personnel files reviewed all three files did not have a documentation of a driver's records check that is required. This was corrected at inspection as all driver's records were ran.

During the inspection of the first aid kit there were a few items missing. There was not a thermometer, tweezers, or waterproof gloves.