Youth Health Associates Glenn Heights Academy

In review of the medication logs, seven prescription medications had lacking documentation showing doses were or were not given, given the wrong number of doses in a day, or given at the wrong time of day.

For medication logs reviewed, two of nine prescription medication did not have documentation of the reason the medication was prescribed.

In review of the medication logs, an as needed psychotropic medication was given on three dates in early December without the specific reason.

2 of 2 case files did not contain support that references were contacted.

2 of 2 files did not contain this document .

1 employee is no longer working with the operation. The case file does not represent the termination-

4 children in care were not provided medications appropriately. As well as 5 prescriptions were not found in the child's medication box.

It was discovered that staff members were monitoring children's phone calls without providing restrictions in the children's service plans.

There was a hole in the wall and pieces of dry wall was on the floor. The toilets were dirty. The doorknob to the Eagle's room is loose.

Children in care were subjected to profane language.

The operation had a loose tile, and a child was able to use that tile to cause harm to self. A loose tile is against the city's ordinance.

The operation did not provide a debrief form for one child in care.

The operation did not follow 3/3 children in care service plans due to supervision.

The debriefing form did not have documentation including the child's response for leaving the facility.

Staff completed a prone personal restrain that lasted more than one minute.

Staff member failed to use self-control meanwhile trying to de-escalate a situation by resorting to making inappropriate comments to child in care about their family.

When reviewing a child's admission assessment, it was observed multiple required information needed at the time of admission wasn't documented on the admission assessment.

Review of the medication administration log revealed discrepancies in the medication count; as no medication errors or refusals were documented.

Three children report that a youth in care expressed discomfort and was not released.

Three children in care reported that force was used during a restraint.

It was noted that a medication error occurred, but it was not documented.

2 out of 2 trainings files reviewed for staff did not have training on pyschotrophic medication by a Health Care professional.

The Unauthorized Absence debriefing was missing the following information: the circumstances that led to the child?s unauthorized absence, the trauma informed strategies the child can use to avoid future unauthorized absences and how the operation can support those strategies, the child?s condition, what occurred while the child was away from the operation (including where the child went, who was with the child, the child?s activities, and any other information that may be relevant to the child?s health and safety), and including any routine activity that would be inappropriate for the child to return to and the explanation for why the activity is inappropriate.

The Unauthorized Absence Log was missing the following information: gender, the time the unauthorized absence was discovered, the name of the caregiver responsible for the child at the time the child's absence was discovered, the intake report number (if a report was made to Licensing or the Department of Family and Protective Services), and whether law enforcement was contacted (including the name of any law enforcement agency that was contacted and the number of the police report, if applicable).

Two unauthorized absences were not documented timely.

During a review of records for Emergency Behavior Intervention. Serious Incident report was reviewed and found to not have the information on who conducted a restraint on a child

During Inspeciton, serious incident report was reviewed. The file reviewed indicated that a child in care had a restraint completed on him. The details of the documentaiton was not in detail. 748.2855(a)- 748.2855(a)(9)

A staff member admitted to falling asleep while on duty.

The child's preliminary service plan states that they will have their own living space, but they were placed in a room with another child in care.

Three out of three files reviewed indicated that there was no signed statement from the employee that he or she will report suspected child abuse, neglect or exploitation

This rule is not addressed in the policies and procedures.

The applicant and the designee do not have a background check submitted.

This rule was not addressed in the policies and procedures.

YHA's policy reporting serious incidents do not align with all the requirements found at 748.105 (8) and 748.303(a)

A description for volunteer responsibilities, the criteria for the selection process, and required training is not explained.

The procedures for obtaining clothing indicate that children will have adequate clothing at placement. The budget does not have a line item for how clothing will be purchased or provided.

On page 253, the specific screening tool and its application is not defined.

The policies and procedures submitted in certain areas speak to the rights of the guardian only.

The policies and procedures do not specify confidentiality requirements for contractors and volunteers.

The policies and procedure do not address this rule.

The staff house is not in an appropriate condition for children in care. The house would need to be cleaned, cleared, and beds added prior to operating. The larger house has several bathroom handles and sink knob that required replacement. Some flooring was soiled. The garage was filled with items to be discarded. The pool house is blocked and in need of repairs/maintenance. The house where the heater is stored is dilapidated and contains discarded items.

In the weapons policy PDF on pg. 242, it states that weapons will be prohibited. However, on page 229 of the YHA policies and procedures it states that children may engage in high-risk activities that include weapons, etc.

The application states that children with emotional disorders will be admitted. However, the admission policies found on pages 118, 124, and 130 conflict.

Conflict of Interest section did not have a statement which informs that governing body does not have a conflict of interest.

The minimum qualification for the PLSP, in YHA's plan, is that the person would have a degree in social work or a bachelor's degree. This is not according to minimum standard rule 748.563(a).