Facility Evaluation Report

On 12-6-23 at 1:15pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding a peer to peer altercation which occurred on 11-27-23. LPA met with program director (PD) Michael Carroll and explained the purpose of the visit. LPA reviewed incident report dated 11-28-23 and conducted brief interview with PD. Based on incident report, on 11-27-23 resident1 (R1) became agitated after another peer, R2 requested to sit in the front seat of the transport van. An altercation resulted which included R1 striking R2 in the left upper arm. Based on incident report and interview, no visible injuries were noted. The driver pulled over and R1 and R2 were separated for safety purposes with no further incident. R1 returned to program on 11-30-23 following the incident and day program staff are continuing to track behaviors and develop de-escalation protocols for R1 for safety purposes.

Incident was reported to licensing department, ombudsman, and local law enforcement within regulatory time frames. An interdisciplinary team meeting was held on 11-29-23 and R1's assessment has been updated to reflect new behavior of peer to peer aggression. Day program is continuing to implement the following: (1) On -going staff training on various mental health topics including but not limited to: De-escalation of behaviors and peer conflicts, identifying triggers for various behaviors, safe intervention techniques regarding aggression and anger. (2) Continued daily rounds conducted in classrooms to help instructors pro-actively identify potential behavior outbursts by clients., (3) Continue weekly staff meetings with emphasis on currently challenging clients and pro-active interventions as necessary. Documentation of above items are in place.

As a result of today's case management, no citations are issued today. An exit interview was conducted with Michael Carroll and a copy of this report was provided to Michael.