Table Of Content

Report of Inspection at the request of the Board of Private Alternative Adolescent Residential Programs Program: Wood Creek Academy, PAP-LIC-564 76 Tanager Lane ‘Thompson Falls MT Inspector: TJ. Hunt Jody Dalbec Date of Inspection: ‘August 15, 2017 Site Inspection: [Note: This was an unannounced site inspection conducted in response to Complaint # 2017-PAP-529,] Comments Plan of operation as described in application its with the appearance of the operation {25 laid out during walk through Wood Creek ie 3 12-month residential program for bovs, No changes to operation ‘The number of program participants is consistent with information submitted with application and provided by Adminstrator. ‘AX the time of the inspection, Wood Creek had 19 participants, This is consletent with the program's 2017 Renewal Comments: ae Comments: 6. Zo Comments: 2 » 0 Comments Premise dose not contain an area that could be used for corporal punishment, iolaion ‘or the ability to inflict physical pain as a disciplinary measure. ‘No area was viewed, This information was lzo confirmed through staff and participant Interviews. ‘Buildings are equipped with ie extinguishers, emergency exits plans and smoke ‘detectors that are placed conspicuously. ‘Any noted deficiencies in most recent Deputy State Fire Marshalls report have been addressed, ‘Sean Thome, WCA Director. was not sure when the last inpection by the State Fire No safety hazards or defects were noted during the inspection, {program is required to have periodic water quality testing and septic maintenance, verify these inspections are current. ‘Water is tested monthly and portable toilets are pumped monthly, Facility contains an adequately supplied first aid kt whichis maintained and in good working order. Wood creek inspection Report ‘August 18,2017 Page 213 Area medications are stored in a controled ares with imited access, BO Feed preparation and serving areas are adequate to ensure nutritional needs of partipants are met. Comments: All areas appeared adequate, W)C) Foodpreparation areas are operated ina clean and safe manner with ll equipment, storage aed erving tock in good working order. Comments: llamas anperad fob in compliance, HO Wehicies used to transport participants and staff has emergency information contained Inthe veil. (Mame, addres, telephone of prosram and emrgency phone numbers) Comments: Emergency information i taken with them inthe vehicle during transport, WW) Verifed fay newiy constructed buildings or remodeling has been done within the ast 18-24 months. If so, determine if building, plumbing and electrical permits were ‘received and proper inspections done upon completion of project. Comments: No new construction has occ Administrator Interview. yon 1) ()__ Aiministrator explained policy for contraband check, including the citcumstances in which searches willbe conducted and the training of staff conducting search, Comments: Me, Thorne explained the process, Wood creek inspection Report ‘August 18,2017 Page 33 Comments: Comments: " #oO Comments: Reviewed with Administrator atleast two personnel files of employees to verity ‘background checks are on file and fingerprint checks have been performed. Personne fls contained copies of fingerprints and background searches, Reviewed with Adminstrator at leat two program participant’ files to veriy they are ‘kept within accordance of programs policy and federal and state law for privacy. ‘Program participant files are stored in a file cabinet located inthe staff office, which i {locked atthe end ofeach day, Participants are not allowed accezs tothe office, Reviewed with Administrator atleast two program participants files to verify that each thas an individual treatment plan in place. (at least one different from above two) ‘Program participant files appeared tobe in compliance, Review medication dispensation log to verify that kept upto date including information ‘on missed or refused dosages and medication changes, ‘Medication log reviewed and appeared to bein compliance, Verify with Administrator that copies of all professional staff certifications are ‘maintained on the premise. ‘Sta certifications were viewed, Staff explained definition of inappropriate and appropriate behaviors of program participants Wood creek inspection Report ‘August 18,2017 Page tof Comments: Staff explained acceptable and unacceptable responses to inappropriate behaviors as well as acceptable consequences to inappropriate behaviors, ‘The program utilizes 2 level system. Participants can earn up to 300 points per day and ‘ate sislgned a level based on the number of points accumulated weekly. As the deipant moves up levels, they are allowed more, 2 and personal items, ©) CO _statt verified training in these areas has occurred and does reoccur at least annually. ‘Comments: Staff described veal trainings 4 ©) (Staff verified the purpose of physical labor (not forthe sole purpose of punishment). ‘Comments: Staff explained physical Isor is part of the program, but not forthe sole purpose of punish 5 BH stat verted necessary food, clothing, bedding, et tlle use or bathing facies are ‘not denied to participants a a form of punishment. Comments: Staff stated alternate meals reserved as form of discipline, which consist of eaten, ‘Powdered mil, and an apple, The alternate meals ar served for a maximum of three dda. Staff leo stated certain articles of clothing are removed a: a deterent, For swample «patipant's pants were taken away when he tried to run avay. Saf also ‘Hated if a participant i placed in separation for bad behavior, he has to shower outside sing» hose and a trp for privacy. 6. ©) CO Stat vered that verbal abuse, ridicule, humilation, profanity, threats rather forms of ‘ogradation ate not directed at participants or their families Comments: Staffindiated this dows not occur, ‘Wood cae spec Repo Dogon 18,2017 Pages of3 Comments Staff verified denial of visits or communication with parents/guardians does not occur {or the sole purpose of punishment (program guidelines, activities, plans or court orders ‘may require short periode where communication cannot occur). Stall. stated the frequency of communication with parents/guardians is dependent on, the participants level, Verified locked confinements or placing participants ina locked room for non- therapeutic purposes are not used. Not used, Verified the administration of medication for disciplinary purposes, the convenience of staff or as a substitute fr treatment services isnot done. ‘Staff verified medication is only administered as prescribed, ‘taf verified all punishment given toa participant is done with at least two staff ‘members present. Verified physical or mental sufering including pain to force compliance does not occur. Doss not occur, ‘The use of passive restraints explained and falls within the program rules (only used in «situation when an imminent threat to the participant, staff or others and only by trained staff CP| and MANDT). Staff verified they ae trained in CP Staff explained use of short term time out for behavior modification methods employed atthe facility. ‘Short term time outs are utilized, Wood Creek inspection Report ‘August 18,2017 Page of3 Comments: Staff explained procedures for handling emergency situations such as suicide threat/attempt, assault or runaway. “Staff explained procedures for handling emergency situations, YON #OoO Comments: Comments: Participants explained how staff deals with inappropriate and appropriate behaviors of ‘program participants Participants described the use of points and the level system, Participants acknowledge having access to routine and emergent medical services 3s needed, including mental health services. Participants confirmed they have unrestricted acces to these services, Participants received handbook outlining expectations and acceptable standards of the program. Participants verified receiving a handbook, Participants verified the purpose of physical labor (not forthe sole purpose of punishment) Participants described physical labor, but not forthe sole purpote of punishment, Participants verified necessary food, clothing, bedding, res, tollet use or bathing {aclities ae not denied to participants as a form of punishment. Wood Creek inspection Report ‘August 18,2017 Page 3 Comments: Participants verified that verbal abuse, ridicule, humilation, profanity, threats or other forms of degradation are nat directed at participants or their families, Participants verified denial of visite or communication with parents/guardiane does not ‘occur fr the sole purpose of punishment (program guidlines activities, plans or court ‘orders may require short periods where communication cannot occur). the frequency of phone cals ic determined by the level system, Locked confinements or placing participant in a locked room for non-therapeutic purposes are not used. ‘No area wae viewed, This information vas alzo confirmed by participant interviews, BO) The administration of medication for disciplinary purposes, the convenience of staf or ‘a substitute fr treatment services in net done. Comments: Does not occur, 10 SO -aticipants verified al punishment given to participant is done with atleast two staff ‘members present. Determine f corporal punishment i sed. Comments: Corporal punishment not used. a BC Physical or mental suffering including pain to force compliance does not occur. Comments: Does not occur, Wood Creek ingpacton Report ‘Ragan 18,2017 Pages of3 2 ‘The use of passive restraints explained and falls within the program rules (only used in «situation when an imminent threat to the participant, staff or others and only by trained staff CP| and MANDT). comments: 2 1) C_Particpant explained use of sor tm ie ot for bshavior modification methods employed atthe faity. Comments: Participants described the use of short term time outs and referred to it as “hold a tree” ‘because they have to keep one hand on 2 tree during the time out, Wee nk napecon Raper Sa itt Page of3