RIDGE CREEK SCHOOL - NEW ORCC REPORT 03-11-2011

http://167.193.144.170:7001/ORSINV/PDFS_CCI/CCI0017106ES811.pdf

Georgia Department of Human Resources,
Office of Regulatory Services State Form
Statement of Deficiencies
and Plan of Correction
Inspection begin date
Inspection end date:
2/3/2011
3/10/2011
Name of Provider or Supplier
RIDGE CREEK, INC
Street Address, City, State Zip Code
830 HIDDEN LAKE RD
DAHLONEGA, GA 30533
Inspection Results
As of: Wednesday, April 13, 2011
R 0000 Opening Comments.
The purpose of this survey was to investigate 92332, 91785, and 92236. Intake 92630 was added
to the survey on February 4, 2011.
R 0801 290-2-5-.08(2) Administration and Organization.
SS=E
Program Description and Implementation. In accordance with these rules and regulations, a licensed child caring
institution shall develop, implement and comply with written policies and procedures that describe the range of
services including room, board
This Requirement is not met as evidenced by:
Based on record review, staff interview, and review of relevant facility documents, the facility
failed to comply with written policies and procedures regarding the admission and supervision.
(GA00091785 and GA00092236)
Findings Include:
ADMISSION POLICY (GA00092236):
(1) Record review on February 4, 2011 of the agency's Admission Requirements Policy #15-100.0
indicated that the agency accepts the following individuals for admission into the program:
Adolescents aged 12-18, or who are in grades 7-12, who would benefit from a
cognitive-behavioral therapy.
Adolescents diagnosed with Oppositional Defiant Disorder (ODD) or who display ODD features.
Adolescents who need leadership training.
The policy further indicated that the agency does not accept the following individuals for
admission into the program:
Adolescents diagnosed with Conduct Disorder or who would fit the profile of Conduct Disorder.
Adolescents who are actively suicidal.
Adolescents with Anti-Social Personality Disorder or who would fit the profile of Anti-Social
Page 1 of 21
More Information Return to Facility Location and Information Guide Return to Inspection Screen
Georgia Department of Human Resources,
Office of Regulatory Services State Form
Statement of Deficiencies
and Plan of Correction
Inspection begin date
Inspection end date:
2/3/2011
3/10/2011
Name of Provider or Supplier
RIDGE CREEK, INC
Street Address, City, State Zip Code
830 HIDDEN LAKE RD
DAHLONEGA, GA 30533
Inspection Results
As of: Wednesday, April 13, 2011
Personality Disorder.
Adolescents who have felony arrest records.
Adolescents who have a history of violence against people or animals.
(2) Record review on February 14, 2011 of Resident #2's file indicated Resident #2 has a history of
violence against people and has a diagnosis of conduct disorder. Specifically, a review of
Resident #2's intake summary (not dated) indicated that Resident #2 is currently released on bail
after his/her involvement in a street fight. Resident #2 was arrested for felony assault. Resident
#2 was placed on intensive supervision probation in which the agency was responsible for
supervising Resident #2. In addition, the intake summary indicated Resident #2 has been verbally
defiant and aggressive and has threatened violence towards his/her mother (a review of
psychiatric discharge summary dated 06-01-2010 from a hospital indicated that Resident #4 was
hospitalized after becoming physically and verbally threatening to his/her mother). Furthermore,
a review of Resident #2's Psychosocial History Intake Summary dated 07-09-10 indicated
Resident #1 was diagnosed with Conduct Disorder.
(3) Record review on February 14, 2011 of Resident #4's application for admission dated
04-26-2009 revealed Resident #4 is currently on probation for burglary and theft however the
agency failed to obtain documentation as to whether the charge was a misdemeanor or felony to
determine if Resident #5 met the criteria for admission. In addition, a review of a discharge
summary from a previous residential treatment program dated 04-28-2009 indicated Resident #4's
final diagnosis included Conduct disorder. Furthermore, a review of Resident #4's
neuropsychological evaluation dated 01-28-2009 revealed a diagnosis of conduct disorder. The
report further indicated that Resident #4 has legal problems involving breaking and entering a
house with robbery resulting in Resident #4 being placed on probation.
(4) Record review on February 14, 2011 of Resident #5's Psychosocial Evaluation dated
11-10-2010 revealed Resident #5 was arrested on robbery charges in which the charges were still
pending at the time of admission. The agency failed to obtain documentation as to whether the
charges were a misdemeanor or felony to determine if Resident #5 met the criteria for admission.
(5) Record review on February 14, 2011 of Resident #6's intake summary (not dated) revealed that
Resident #6 physically bullies his/her sister as well as in 2009 threatened his/her father with a
knife resulting in police intervention and eventually a six day hospitalization for Resident #6.
(6) During an interview on February 1, 2011 at about 11:01 AM with Staff PP, Staff PP indicated
that the admission exclusions include residents who are violent, court ordered, or sexual
Page 2 of 21
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Georgia Department of Human Resources,
Office of Regulatory Services State Form
Statement of Deficiencies
and Plan of Correction
Inspection begin date
Inspection end date:
2/3/2011
3/10/2011
Name of Provider or Supplier
RIDGE CREEK, INC
Street Address, City, State Zip Code
830 HIDDEN LAKE RD
DAHLONEGA, GA 30533
Inspection Results
As of: Wednesday, April 13, 2011
perpetrators. Staff PP indicated that they have never accepted a child with a history of sexual
perpetration however the agency has accepted residents who were court ordered. For example,
Resident #2 and Resident #5 were court ordered, which is a direct violation of their admission
policy.
(7) During an interview on February 9, 2011 at about 2:32 PM with Staff OO, Staff OO indicated
that the agency typically admits residents who have a diagnosis of ADHD, anxiety, or depression.
Staff OO indicated that the agency does not admit residents who have a history of violent
tendencies or conduct disorder.
SUPERVISION POLICY (GA00091785):
(8) Record review on February 4, 2011 of the agency's Night Security Policy #8-106 revealed that
the agency provides 24-hour staffing through the utilization of night security in the dormitories.
The security personnel (staff assigned to the night shift) are responsible for the health and
welfare of students during the night shift whenever students spend the night in the dorm. The
primary responsibility of the security staff is to maintain accountability and safety of the students
at all times. The policy also indicated that the night security must maintain a security post that
has observation of all rooms. This can be accomplished from the hallway outside of the common
room. In addition, night security must conduct random physical security checks and headcounts
no more than twenty minutes apart.
(9) During an interview on February 2, 2011 at about 1:41 PM with Resident #103, Resident #103
indicated that on the early morning of 01-16-2011, she/he along with three other residents (
Residents #102, #105, and #108) eloped from the facility unbeknown to staff until they were
returned to the facility around 4:30 AM by the local sheriff. Resident #103 indicated that they left
through a broken window that was boarded up in his/her room. Resident #103 further indicated
that the window was boarded with nails in which they utilized some tools to loosen the board in
order to elope from the facility. Resident #103 also indicated that they were gone for a few hours
in that they were able to make it to a local store which is about 10 miles away from the school.
(10) During an interview on February 4, 2011 at about 2:45 PM with Staff NN, Staff NN
acknowledged that several residents eloped during the early morning of 01-16-2011 through a
broken window that was boarded up. Staff NN indicated that she/he was not aware that the
residents had left until they were returned to the home around 4 AM by the local sheriff. Staff NN
indicated that it was later discovered that the residents had stuffed clothes in their beds to make
it look as if they were in their beds. Staff NN indicated that room checks are conducted every 15
Page 3 of 21
More Information Return to Facility Location and Information Guide Return to Inspection Screen
Georgia Department of Human Resources,
Office of Regulatory Services State Form
Statement of Deficiencies
and Plan of Correction
Inspection begin date
Inspection end date:
2/3/2011
3/10/2011
Name of Provider or Supplier
RIDGE CREEK, INC
Street Address, City, State Zip Code
830 HIDDEN LAKE RD
DAHLONEGA, GA 30533
Inspection Results
As of: Wednesday, April 13, 2011
minutes however when she/he conducted the bed checks, it consisted of ensuring that a body
was in the bed rather than physically observing a resident in the bed as stated in the agency's
policy.
(11) During an interview on February 14, 2011 at about 3:25 PM with Staff QQ, Staff QQ indicated
that staff are to conduct bed checks every 15-20 minutes. The bed checks should consist of
physically observing a resident in his/her designated bed.
This rule was previously cited 09-09-2010.
Page 4 of 21
More Information Return to Facility Location and Information Guide Return to Inspection Screen
Georgia Department of Human Resources,
Office of Regulatory Services State Form
Statement of Deficiencies
and Plan of Correction
Inspection begin date
Inspection end date:
2/3/2011
3/10/2011
Name of Provider or Supplier
RIDGE CREEK, INC
Street Address, City, State Zip Code
830 HIDDEN LAKE RD
DAHLONEGA, GA 30533
Inspection Results
As of: Wednesday, April 13, 2011
R 0833 290-2-5-.08(5)(d)4. Recordkeeping. Personnel Records.
SS=C
[Written personnel records] records shall include the following: ...
4. Documentation of at least two professional, educational, or personal references that attest to the person's
capabilities of performing the duties for which they are employed and to t
This Requirement is not met as evidenced by:
Based on a review of personnel files and staff interview, the agency failed to document at least
two professional, educational, or personal references that attest to the person's capabilities of
performing the duties for which they are employed and to the person's suitability of working with
or around children in two of seven personnel files reviewed (GA00092332).
Findings Include:
(1) Record review on February 14, 2011 of Staff B's file revealed that Staff B was hired on
01-03-2011 and the agency failed to maintain documentation of at least two references.
(2) During an interview on February 14, 2011 at about 4:45 PM with Staff QQ, Staff QQ
acknowledged findings after reviewing the personnel file for Staff B. Staff QQ indicated that some
of the information had not been filed in the staff members records however, Staff QQ was
provided the opportunity to provide the un-filed documents for review. Staff QQ indicated that the
missing information was not observed among the un-filed documents
This rule was previously cited 12-15-2010 and 09-09-2010.
Page 5 of 21
More Information Return to Facility Location and Information Guide Return to Inspection Screen
Georgia Department of Human Resources,
Office of Regulatory Services State Form
Statement of Deficiencies
and Plan of Correction
Inspection begin date
Inspection end date:
2/3/2011
3/10/2011
Name of Provider or Supplier
RIDGE CREEK, INC
Street Address, City, State Zip Code
830 HIDDEN LAKE RD
DAHLONEGA, GA 30533
Inspection Results
As of: Wednesday, April 13, 2011
R 0835 290-2-5-.08(5)(d)6. Recordkeeping. Personnel Records.
SS=C
[Written personnel records] records shall include the following: ...
6. Documentation from a licensed physician or other licensed healthcare professional of a health screening
examination within thirty (30) days of hiring sufficient in scope to identify
This Requirement is not met as evidenced by:
Based on review of personnel files and staff interview, the agency failed to document a health
statement within 30 days of hiring in two of seven personnel files reviewed (GA00092332)
Findings Include:
(1) Record review on February 14, 2011 of Staff B (date of hire 01-03-2011) and Staff D's (date of
hire 01-06-2011) file revealed the agency failed to maintain documentation of a health statement.
(2) During an interview on February 14, 2011 at about 4:45 PM with Staff QQ, Staff QQ
acknowledged findings after reviewing the personnel file for Staff B and Staff D. Staff QQ
indicated that some of the information had not been filed in the staff members' records however,
Staff QQ was provided the opportunity to provide the un-filed documents for review. Staff QQ
indicated that the missing information was not observed among the un-filed documents.
This rule was previously cited 12-15-2010 and 09-09-2010.
Page 6 of 21
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Georgia Department of Human Resources,
Office of Regulatory Services State Form
Statement of Deficiencies
and Plan of Correction
Inspection begin date
Inspection end date:
2/3/2011
3/10/2011
Name of Provider or Supplier
RIDGE CREEK, INC
Street Address, City, State Zip Code
830 HIDDEN LAKE RD
DAHLONEGA, GA 30533
Inspection Results
As of: Wednesday, April 13, 2011
R 0838 290-2-5-.08(5)(d)9. Recordkeeping. Personnel Records.
SS=B
[Written personnel records] records shall include the following: ...
9. Documentation of orientation and training, including dates of all such training, as required by Rule .08(6)(d) of
these rules; ...
This Requirement is not met as evidenced by:
Based on review of personnel files and staff interview, the agency failed to document orientation
and training in two of seven personnel files reviewed (GA00092332)
Findings Include:
(1) Record review on February 14, 2011 of Staff B (date of hire 01-03-2011) and Staff D's (date of
hire 01-06-2011) file revealed that there was no documentation to support that orientation and
training had been provided to each staff member.
(2) During an interview on February 14, 2011 at about 4:45 PM with Staff QQ, Staff QQ
acknowledged findings after reviewing the personnel file for Staff B and Staff D. Staff QQ
indicated that some of the information had not been filed in the staff members' records however,
Staff QQ was provided the opportunity to provide the un-filed documents for review. Staff QQ
indicated that the missing information was not observed among the un-filed documents.
This rule was previously cited 09-09-2010.
Page 7 of 21
More Information Return to Facility Location and Information Guide Return to Inspection Screen
Georgia Department of Human Resources,
Office of Regulatory Services State Form
Statement of Deficiencies
and Plan of Correction
Inspection begin date
Inspection end date:
2/3/2011
3/10/2011
Name of Provider or Supplier
RIDGE CREEK, INC
Street Address, City, State Zip Code
830 HIDDEN LAKE RD
DAHLONEGA, GA 30533
Inspection Results
As of: Wednesday, April 13, 2011
R 0839 290-2-5-.08(5)(d)10. Recordkeeping. Personnel Records.
SS=B
[Written personnel records] records shall include the following: ...
10. Any documentation of the individual's performance, including all records of employee discipline arising from
the inappropriate use of behavior management techniques and emergency sa
This Requirement is not met as evidenced by:
Based on review of personnel files and staff interview, the agency failed to provide
documentation of a performance evaluation in two of seven personnel files reviewed.
(GA00092332)
Findings Include:
(1) Record review on February 14, 2011 of Staff E and Staff F's file revealed the agency failed to
maintain documentation of an annual performance evaluation.
(2) During an interview on February 14, 2011 at about 4:45 PM with Staff QQ, Staff QQ
acknowledged findings after reviewing the personnel file for Staff E and Staff F. Staff QQ
indicated that some of the information had not been filed in the staff members' records however,
Staff QQ was provided the opportunity to provide the un-filed documents for review. Staff QQ
indicated that the missing information was not observed amongst the un-filed documents.
This rule was previously cited 12-15-2010.
R 0840 290-2-5-.08(6) Staffing.
SS=F
Page 8 of 21
More Information Return to Facility Location and Information Guide Return to Inspection Screen
Georgia Department of Human Resources,
Office of Regulatory Services State Form
Statement of Deficiencies
and Plan of Correction
Inspection begin date
Inspection end date:
2/3/2011
3/10/2011
Name of Provider or Supplier
RIDGE CREEK, INC
Street Address, City, State Zip Code
830 HIDDEN LAKE RD
DAHLONEGA, GA 30533
Inspection Results
As of: Wednesday, April 13, 2011
Staffing. The institution shall have sufficient numbers of qualified and trained staff as required by these rules to
provide for the needs, care, protection, and supervision of children. All staff and volunteers shall be supervised to
ensure that assigne
This Requirement is not met as evidenced by:
****Based on record review, resident and staff interviews, the agency failed to provide for the
needs, care, protection, and supervision of the children in care.
Findings Include:
(1) Record review on February 4, 2011 of agency's Night Security Policy #8-106 revealed that the
agency provides 24-hour staffing through the utilization of night security in the dormitories. The
security personnel (staff assigned to the night shift) are responsible for the health and welfare of
students during the night shift whenever students spend the night in the dorm. The primary
responsibility of the security staff is to maintain accountability and safety of the students at all
times. The policy also indicated that the night security must maintain a security post that has
observation of all rooms. This can be accomplished from the hallway outside of the common
room. In addition, night security must conduct random physical security checks and headcounts
no more than twenty minutes apart.
(2) During an interview on February 2, 2011 at about 1:41 PM with Resident #103, Resident #103
indicated that on the early morning of 01-16-2011, she/he along with three other residents (
Residents #102, #105, and #108) eloped from the facility unbeknownst to staff until they were
returned the facility around 4:30 AM by the local sheriff. Resident #103 indicated that they left
through a broken window that was boarded up in his/her room. Resident #103 further indicated
that the window was boarded with nails and they utilized some tools found at the facility to
loosen the board in order to elope from the facility. Resident #103 also indicated that they were
gone for a few hours in that they were able to make it to a local store which is about 10 miles
away from the school.
(3) During an interview on February 4, 2011 at about 2:45 PM with Staff NN, Staff NN
acknowledged that several residents eloped during the early morning of 01-16-2011 through a
broken window that was boarded up. Staff NN indicated that she/he was not aware that the
residents had left until they were returned to the home around 4 AM by the local sheriff. Staff NN
indicated that it was later discovered that the residents had stuffed clothes in their beds to make
it look as if they were in their beds. Staff NN indicated that room checks are conducted every 15
minutes however when she/he conducted the bed checks, it consisted of ensuring that a body
Page 9 of 21
More Information Return to Facility Location and Information Guide Return to Inspection Screen
Georgia Department of Human Resources,
Office of Regulatory Services State Form
Statement of Deficiencies
and Plan of Correction
Inspection begin date
Inspection end date:
2/3/2011
3/10/2011
Name of Provider or Supplier
RIDGE CREEK, INC
Street Address, City, State Zip Code
830 HIDDEN LAKE RD
DAHLONEGA, GA 30533
Inspection Results
As of: Wednesday, April 13, 2011
was in the bed rather than physically observing a resident in the bed as stated in the agency's
policy.
(4) During an interview on February 14, 2011 at about 3:25 PM with Staff QQ, Staff QQ indicated
that staff are to conduct bed checks every 15-20 minutes. The bed checks should consist of
physically observing a resident in his/her designated bed.
This rule was previously cited 01-13-2011, 09-09-2010 and 07-21-2010.
Page 10 of 21
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Georgia Department of Human Resources,
Office of Regulatory Services State Form
Statement of Deficiencies
and Plan of Correction
Inspection begin date
Inspection end date:
2/3/2011
3/10/2011
Name of Provider or Supplier
RIDGE CREEK, INC
Street Address, City, State Zip Code
830 HIDDEN LAKE RD
DAHLONEGA, GA 30533
Inspection Results
As of: Wednesday, April 13, 2011
R 0861 290-2-5-.08(7) Staffing.
SS=C
Reporting. Detailed written summary reports shall be made to the Department of Human Resources, Office of
Regulatory Services, Residential Child Care Unit via email or fax on the required incident intake information form
(IIIF) within 24 hours.
This Requirement is not met as evidenced by:
Based on record review, resident and staff interviews, the agency failed to submit a detailed
written summary report to the Department of Human Services, Office of Residential Child Care
(ORCC) via e-mail or fax on the required incident intake information form (IIIF) within 24 hours in
one of one incident reviewed (GA00092236).
Findings Include:
(1) Record review on February 4, 2011 of the agency's Reporting of Abuse Policy #8-104.0
indicated that all suspicions of child abuse, sexual abuse/exploitation, child neglect, or student
on student abusive sexual contact involving any Ridge Creek student shall be reported
immediately in compliance with Georgia law. All allegations of abuse will be reported to the
Department of Family and Children Services (DFCS). The agency defined mistreatment of
students as a violation of the agency's policy with no injury to the student, including slapping,
shoving, kicking, biting, and spitting at/on a student.
.
(2) During an interview on February 2, 2011 at about 11:30 AM to about 4:15 PM with Residents
#103, #104, #105, #106, #107, and #109, the residents disclosed that there was an incident in
which Staff AA shoved Resident #118 across the hall. The incident was caught on video. The
incident was not reported to ORCC.
(3) During an interview on February 1, 2011 at about 11:01 AM with Collateral Contact A,
Page 11 of 21
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Georgia Department of Human Resources,
Office of Regulatory Services State Form
Statement of Deficiencies
and Plan of Correction
Inspection begin date
Inspection end date:
2/3/2011
3/10/2011
Name of Provider or Supplier
RIDGE CREEK, INC
Street Address, City, State Zip Code
830 HIDDEN LAKE RD
DAHLONEGA, GA 30533
Inspection Results
As of: Wednesday, April 13, 2011
Collateral Contact A indicated that she/he was informed that a student was pushed into a wall by
a staff member in the male dorm. Collateral Contact A indicated that the incident was caught on
video.
(4) During an interview on February 14, 2011 at about 3:25 PM with Staff QQ, Staff QQ indicated
that she/he was not aware of the incident between Staff AA and Resident #118. Staff QQ indicated
that Staff AA wrote an incident report about the incident as a relocation(moving the resident from
one location to another) however after reviewing the video footage of the incident, Staff AA did
not utilize any Mindset approved techniques. Staff QQ indicated that Staff AA was a Mindset
instructor for the agency in which Staff AA was responsible for teaching verbal de-escalation
procedures and reviewing incidents to ensure compliance with Mindset techniques.
This rule was previously cited 12-09-2010 and 09-09-2010.
R 0862 290-2-5-.08(7)(a-g) Staffing.
SS=C
This [detailed written summary] report shall be made regarding serious occurrences involving children in care,
including but not limited to:
(a) Accidents or injuries requiring medical treatment and/or hospitalization;
(b) Death;
(c) Suicide attempts;
Page 12 of 21
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Georgia Department of Human Resources,
Office of Regulatory Services State Form
Statement of Deficiencies
and Plan of Correction
Inspection begin date
Inspection end date:
2/3/2011
3/10/2011
Name of Provider or Supplier
RIDGE CREEK, INC
Street Address, City, State Zip Code
830 HIDDEN LAKE RD
DAHLONEGA, GA 30533
Inspection Results
As of: Wednesday, April 13, 2011
(
This Requirement is not met as evidenced by:
Based on record review, Dekalb Co DFCS CPS investigation notes, and staff interview, the
agency failed to report incidents regarding serious occurrences involving children in care in one
of one incident reviewed;
Findings Include:
(1) Record review on February 4, 2011 of the agency's Reporting of Abuse Policy #8-104.0
indicated that all suspicions of child abuse, sexual abuse/exploitation, child neglect, or student
on student abusive sexual contact involving any Ridge Creek student shall be reported
immediately in compliance with Georgia law. All allegations of abuse will be reported to the
Department of Family and Children Services (DFCS). The agency defined mistreatment of
students as a violation of the agency's policy with no injury to the student, including slapping,
shoving, kicking, biting, and spitting at/on a student.
.
(2) During an interview on February 2, 2011 at about 11:30 AM to about 4:15 PM with Residents
#103, #104, #105, #106, #107, and #109, the residents disclosed that there was an incident in
which Staff AA shoved Resident #118 across the hall. The incident was caught on video. The
incident was not reported to ORCC.
(3) During an interview on February 1, 2011 at about 11:01 AM with Collateral Contact A,
Collateral Contact A indicated that she/he was informed that a student was pushed into a wall by
a staff member in the male dorm. Collateral Contact A indicated that the incident was caught on
video.
(4) During an interview on February 14, 2011 at about 3:25 PM with Staff QQ, Staff QQ indicated
that she/he was not aware of the incident between Staff AA and Resident #118. Staff QQ indicated
that Staff AA wrote an incident report about the incident as a relocation(moving the resident from
one location to another) however after reviewing the video footage of the incident, Staff AA did
not utilize any Mindset approved techniques. Staff QQ indicated that Staff AA was a Mindset
instructor for the agency in which Staff AA was responsible for teaching verbal de-escalation
procedures and reviewing incidents to ensure compliance with Mindset techniques.
This rule was previously cited 12-09-2010 and 09-09-2010.
Page 13 of 21
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Georgia Department of Human Resources,
Office of Regulatory Services State Form
Statement of Deficiencies
and Plan of Correction
Inspection begin date
Inspection end date:
2/3/2011
3/10/2011
Name of Provider or Supplier
RIDGE CREEK, INC
Street Address, City, State Zip Code
830 HIDDEN LAKE RD
DAHLONEGA, GA 30533
Inspection Results
As of: Wednesday, April 13, 2011
Cross reference Tag 861
R 0907 290-2-5-.09(2)(b) Referral and Admission.
SS=B
Prior to admission, the facility shall:
1. Provide information to the custodian about the services, environment, age ranges and behavioral
characteristics of the other children in placement.
2. Maintain signed documentation from the custodian that
This Requirement is not met as evidenced by:
Based on record review and staff interview, the agency failed to provide information to the
custodian about the behavioral characteristics of the other children in placement in six of six
files reviewed (GA00092236).
(1) Record review on February 14, 2011 of Residents #1, #2, #3, #4, #5, and #6's file revealed the
agency failed to provide the custodian/placing agency documentation regarding the services that
will be received and the current behavioral characteristics of the children in placement.
(2) During an interview on February 14, 2011 at about 3:25 PM with Staff QQ, Staff QQ
acknowledged findings.
This rule was previously cited 12-09-2010.
R 1402 290-2-5-.14(1)(b)2. Behavior Management.
Page 14 of 21
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Georgia Department of Human Resources,
Office of Regulatory Services State Form
Statement of Deficiencies
and Plan of Correction
Inspection begin date
Inspection end date:
2/3/2011
3/10/2011
Name of Provider or Supplier
RIDGE CREEK, INC
Street Address, City, State Zip Code
830 HIDDEN LAKE RD
DAHLONEGA, GA 30533
Inspection Results
As of: Wednesday, April 13, 2011
SS=E
Such Behavior management policies and procedures shall incorporate the following minimum requirements: ...
2. Behavior management shall be limited to the least restrictive appropriate method, as described in the child's
service plan pursuant to Rule
This Requirement is not met as evidenced by:
Based on record review, resident and staff interview, the agency failed to ensure that behavior
management was limited to the least restrictive appropriate method, as described in the child's
Room, Board, and Watchful Oversight Plan and in accordance with the prohibitions as specified
in the rules and regulations (GA00092236).
Findings Include:
(1) Record review on February 4, 2011 of the agency's Reporting of Abuse Policy #8-104.0
revealed that the agency defined mistreatment of students as a violation of the agency's policy
with no injury to the student to including slapping, shoving, kicking, biting, and spitting at/on a
student.
.
(2) During an interview on February 1, 2011 at about 11:01 AM with Collateral Contact A,
Collateral Contact A indicated that she/he was informed that a student was pushed into a wall by
a staff member in the male dorm. Collateral Contact A indicated that the incident was caught on
video.
(3) During an interview on February 2, 2011 at about 11:30 AM to about 4:15 PM with Residents
#103, #104, #105, #106, #107, and #109, the residents disclosed that there was an incident in
which Staff AA shoved Resident #118 across the hall. The incident was caught on video. The
incident was not reported to ORCC.
(4) During an interview on February 1, 2011 at about 11:01 am with Staff PP, Staff PP indicated
that when she/he became aware of the incident with Staff AA and Resident #118, Staff PP
indicated that Staff QQ was notified and they reviewed the video footage. According to his/her
observation of the video footage, Staff AA was observed standing in the doorway of a resident
room along with another staff member nearby in the hallway. Resident #118 was observed
standing around with other students. Staff PP indicated that it appeared that Resident #118 was
instigating Staff AA however there is no audio to confirm the verbal exchange between the two.
Page 15 of 21
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Georgia Department of Human Resources,
Office of Regulatory Services State Form
Statement of Deficiencies
and Plan of Correction
Inspection begin date
Inspection end date:
2/3/2011
3/10/2011
Name of Provider or Supplier
RIDGE CREEK, INC
Street Address, City, State Zip Code
830 HIDDEN LAKE RD
DAHLONEGA, GA 30533
Inspection Results
As of: Wednesday, April 13, 2011
Resident #118 was observed walking in and out of the bedroom several times when Staff AA was
observed pushing Resident #118 causing Resident #118 to end up on the other side of the
hallway. Staff PP indicated that Resident #118 was interviewed about the incident and did not
appear upset about the incident. Resident #118 indicated that she/he deserved to be pushed by
Staff AA. Staff QQ spoke with Staff AA a week after reviewing the video.
(5) During an interview on February 4, 2011 at about 2:45 PM with Staff NN, Staff NN
acknowledged witnessing the incident with Staff AA and Resident #118. Staff NN indicated that
Resident #118 got in Staff AA's face. Staff AA warned Resident #118 several times to back off
however Resident #118 continued to get in Staff AA's face therefore, Staff AA pushed Resident
118 out of the way. Staff NN described the push as a hard shove causing Resident #118 to
stumble backwards about 2 1/2-3 feet from Staff AA. Staff NN acknowledged that Resident #118
did not physically touch Staff AA. Staff NN indicated that she/he did not feel that the push was
inappropriate and/or abusive due to the fact that Resident #118 approached Staff AA in an
aggressive manner.
(6) During an interview on February 9, 2011 at about 12:56 PM with Staff MM, Staff MM indicated
that she/he was informed of the incident in which Staff AA shoved a resident. Staff MM indicted
that the incident was caught on video. Staff MM further indicated that during a conversation with
Staff AA, Staff AA acknowledged to shoving the resident and that she/he could have handled the
incident differently however the resident had Staff AA trapped. Staff AA disclosed to Staff MM
that she/he was verbally reprimanded by Staff QQ about the incident.
(7) During an interview on February 14, 2011 at about 3:25 PM with Staff QQ, Staff QQ indicated
that she/he was not aware of the incident between Staff AA and Resident #118. Staff QQ indicated
that Staff AA wrote an incident report about the incident as a relocation (moved the resident from
one location to another location) however after reviewing the video footage of the incident, Staff
AA did not utilize any Mindset approved techniques. Staff QQ indicated that Staff AA was a
mindset instructor for the agency in which Staff AA was responsible for teaching verbal
de-escalation procedures and reviewing incident to ensure compliance with Mindset techniques.
(8) During an interview on February 9, 2011 at about 2:40 PM with Staff UU, Staff UU indicated
that she/he observed the video of the incident between Staff AA and Resident #118. Staff UU
indicated that she/he observed Resident #118 walk out of the bedroom and turn around and say
something and walk out the room. Staff AA walked out the room and pushed Resident #118
aggressively causing Resident #118 to stumble almost hitting the wall. Staff UU indicated that
she/he did not observe Resident #118 display any physical aggression towards Staff AA, however
Page 16 of 21
More Information Return to Facility Location and Information Guide Return to Inspection Screen
Georgia Department of Human Resources,
Office of Regulatory Services State Form
Statement of Deficiencies
and Plan of Correction
Inspection begin date
Inspection end date:
2/3/2011
3/10/2011
Name of Provider or Supplier
RIDGE CREEK, INC
Street Address, City, State Zip Code
830 HIDDEN LAKE RD
DAHLONEGA, GA 30533
Inspection Results
As of: Wednesday, April 13, 2011
according to an incident report completed by Staff AA, Staff AA documented that Resident #118
tried to grab his/her shirt.
(9) Record review on February 14, 2011 of Incident Report dated 12-18-2010 completed by Staff
AA, Staff AA documented that around 10:32 PM, Resident #118 was found in another student ' s
room and was given 3 days reflection (behavioral consequence). Resident #118 left the room and
entered the hallway. Resident #118 approached Staff AA by getting into Staff AA's face in an
aggressive posture, blocking staff 's exit from the room. Resident #118 was advised multiple
times not to approach staff 's personal space. Resident #118 was pushed away from Staff AA to
position for a leveraged embrace. Resident #118 moved away and Staff AA was able to position
self with an escape route. Resident #118 did not pose a threat and was directed to go into his/her
room.
(10) Observation of agency video footage on February 10, 2011 revealed that on 12-18-2010 at
about 10:20 PM , two residents and Staff AA were observed standing in the hallway of the boys'
dorm outside of the bedroom of one of the male residents. Resident #118 was observed walking
in the room then she/he walked out of the room followed by Staff AA. Resident #118 turned
towards Staff AA. Staff AA was observed forcibly shoving Resident #118 causing Resident #118
to stumble towards the other side of the wall about a foot or two away. At no point was Resident
#118 observed being physically aggressive with Staff AA.
(11) Record review on February 14, 2011 of Resident #118's individual service plan dated
10-29-2010 revealed the agency utilizes natural and logical consequences for behavior
management. Punitive punishments are not utilized. The use of group consequences will be
utilized based on the agency's peer group model. The agency is a hands-off facility, however all
staff are certified in TACT-2 restraints( the staff initially used TACT 2 but are now transitioning to
Mindset) in the event that a student is causing harm to himself/herself or others.
This rule was previously cited 07-21-2010.
Page 17 of 21
More Information Return to Facility Location and Information Guide Return to Inspection Screen
Georgia Department of Human Resources,
Office of Regulatory Services State Form
Statement of Deficiencies
and Plan of Correction
Inspection begin date
Inspection end date:
2/3/2011
3/10/2011
Name of Provider or Supplier
RIDGE CREEK, INC
Street Address, City, State Zip Code
830 HIDDEN LAKE RD
DAHLONEGA, GA 30533
Inspection Results
As of: Wednesday, April 13, 2011
R 1408 290-2-5-.14(1)(c)6. Behavior Management.
SS=D
The following forms of behavior management shall not be used: ...
6. Verbal abuse, ridicule, or humiliation; ...
This Requirement is not met as evidenced by:
Based on record review, staff and resident interviews, the agency failed to refrain from verbal
abuse as a form of behavior management (GA00092236)
Findings Include:
(1) During an interview on February 1, 2011 at about 11:01 AM with Staff PP, Staff PP indicated
that she/he was informed by Residents #102, #115, and #118 that Staff AA has been verbally
abusive towards them by yelling at them when Staff AA was angry or taunting them. In addition,
there were reports made by residents that other staff members have been taunting them.
(2) During an interview on February 2, 2011 at about 11:30 AM to about 4:15 PM with Residents
#103, #104, #105, #106, #107, and #109, it was revealed that on several occasions staff have been
emotionally and/or verbally abusive to include cursing at them, yelling, and making demeaning
remarks against their character. Specifically, Resident #103 indicated that Staff UU made a
sexually inappropriate comment when placing Resident #103 and Resident #111 on peer
restriction. Staff UU referred to the peer restriction for Residents #103 and Resident #111 as
"penis" band. During interviews with Residents #104, #105, #106, and #107, it was disclosed that
Staff AA would curse, yell, and call them inappropriate names.
(3) According to Lumpkin Co DFCS investigation, the case was substantiated for abuse/neglect
due to interviews conducted with residents and staff who collaborated that l other staff members
were known to be emotionally and verbally abusive towards residents by calling them
inappropriate names, cursing, making inappropriate statements, and yelling at the residents.
(4) During an interview on February 9, 2011 at about 12:56 PM with Staff MM, Staff MM
acknowledged that she/he was aware of incidents of verbal abuse in which some residents have
voiced concerns regarding Staff UU's inappropriate comment made to some female residents in
which Staff UU referred to a boy/peer band as a "penis" band. There have been reports from
Page 18 of 21
More Information Return to Facility Location and Information Guide Return to Inspection Screen
Georgia Department of Human Resources,
Office of Regulatory Services State Form
Statement of Deficiencies
and Plan of Correction
Inspection begin date
Inspection end date:
2/3/2011
3/10/2011
Name of Provider or Supplier
RIDGE CREEK, INC
Street Address, City, State Zip Code
830 HIDDEN LAKE RD
DAHLONEGA, GA 30533
Inspection Results
As of: Wednesday, April 13, 2011
residents that Staff UU has called residents inappropriate names. Staff MM indicated that she/he
would address the issues with the staff member directly informing the staff member of his/her
inappropriateness of his/her actions. Staff MM indicated that residents have reported that a
teacher called a resident retarded. In addition, there have been reports made against Staff AA by
residents in which Staff AA has been involved in verbal power struggles with residents. A
resident submitted a global e-mail to staff members acknowledging an incident in which Staff AA
was verbally/emotionally abusive to the male students after an inappropriate e-mail was sent to
the girl dorm. It was reported that Staff AA cursed the residents and was verbally threatening
towards some of the residents.
(4) During an interview on February 9, 2011 at about 2:40 PM with Staff UU, Staff UU indicated
she/he has witnessed Staff AA being verbally abusive with the residents by yelling and cursing at
the residents. Staff AA approach the residents in a verbally threatening way. Other staff members
no longer employed with the agency have been known to curse at the residents. Staff UU
indicated that there was an incident in which Staff AA confronted the male dorm due to an
inappropriate e-mail sent to the girl's dorm in which the residents reported that Staff AA was
cursing and threatening them. Staff UU acknowledged to making an inappropriate comment to
Residents #103 and #111 by referring to a male peer band as "penis" band.
(5) During an interview on February 9, 2011 at about 3:15 PM with Staff HH, Staff HH indicated
that she/he was informed of an incident when Staff UU made a derogatory remark to two female
residents. In addition, some residents have reported that they have been cursed at by staff. Staff
HH indicated that Staff AA was a staff member the residents complained about being verbally
abusive.
(6) During an interview on February 14, 2011 at about 3:25 PM with Staff QQ, Staff QQ indicated
that Staff AA received a verbal reprimand when she/he became aware of Staff AA's handling of
residents when the male residents sent an inappropriate e-mail to the female dorm. Staff AA
indicated that she/he addressed appropriate verbal exchange to include not to threaten and/or
curse at the residents. Staff QQ further indicated that Staff AA was the agency's Mindset trainer
responsible for teaching verbal de-escalation procedures and reviewing incidents to ensure
compliance with Mindset techniques.
(7) Record review on February 14, 2011 of e-mail dated 12-15-2010 by Resident #121, Resident
#121 wrote a grievance about the treatment the residents received at the hands of staff to include
being talked down to and threatened by staff. Resident #121 specifically talked about an incident
that occurred on 12-12-2010 in which Staff AA cursed and threatened the students after some
Page 19 of 21
More Information Return to Facility Location and Information Guide Return to Inspection Screen
Georgia Department of Human Resources,
Office of Regulatory Services State Form
Statement of Deficiencies
and Plan of Correction
Inspection begin date
Inspection end date:
2/3/2011
3/10/2011
Name of Provider or Supplier
RIDGE CREEK, INC
Street Address, City, State Zip Code
830 HIDDEN LAKE RD
DAHLONEGA, GA 30533
Inspection Results
As of: Wednesday, April 13, 2011
male peers sent an inappropriate note to the girls ' dorm.
(8) Record review on February 14, 2011 of e-mail dated 02-01-2011 by Resident #103, Resident
#103 submitted the letter to Staff UU and Staff QQ stated that she/he and Resident #111 felt
disrespected due to the rude and misleading comment made by Staff UU.
R 1903 290-2-5-.19(1)(a) Enforcement and Penalties.
SS=D
The institution shall comply with an accepted plan of correction.
This Requirement is not met as evidenced by:
Based on record review and staff interview, the agency failed to comply with an acceptable plan
of correction.
Findings Include:
(1) Record review on March 1, 2011 of plan of correction submitted for survey ID F6XP11 dated
January 26, 2011 indicated that an internal audit of personnel files was conducted on 12/23/10.
In-service training days were held over Winter Break 12/23/10-01/02/10 and on 01/25/11 to get
deficient staff current with their missed Orientation Training topics. As of 01/25/11, all staff were
current in their required trainings. In addition, in regards to employee health screenings, all
employees were given until 01/15/2011 to complete the required health screenings to continue
with fitness for duty. All current employees have submitted their required health screenings as
of 01/25/11.
(2) Record review on February 14, 2011 of Staff B (date of hire 01-03-2011) and Staff D's (date of
hire 01-06-2011) file revealed the agency failed to maintain documentation of a health statement.
(3) Record review on February 14, 2011 of Staff B (date of hire 01-03-2011) and Staff D's (date of
hire 01-06-2011) file revealed that there was no documentation to support that orientation and
Page 20 of 21
More Information Return to Facility Location and Information Guide Return to Inspection Screen
Georgia Department of Human Resources,
Office of Regulatory Services State Form
Statement of Deficiencies
and Plan of Correction
Inspection begin date
Inspection end date:
2/3/2011
3/10/2011
Name of Provider or Supplier
RIDGE CREEK, INC
Street Address, City, State Zip Code
830 HIDDEN LAKE RD
DAHLONEGA, GA 30533
Inspection Results
As of: Wednesday, April 13, 2011
training had been provided to each staff member.
(4) During an interview on February 14, 2011 at about 4:45 PM with Staff QQ, Staff QQ
acknowledged findings after reviewing the personnel file for Staff B and Staff D . Staff QQ
indicated that some of the information had not been filed in the staff members' records however,
Staff QQ was provided the opportunity to provide the un-filed documents for review. Staff QQ
indicated that the missing information was not observed amongst the un-filed documents
R 9999 Closing Comments.
A brief exit conference was conducted on February 14, 2011. A preliminary report was e-mailed to
the agency on March 11, 2011. A formal written plan of correction is due to the surveyor 10 days
after receipt of this final Statement of Deficiencies.
The investigation was concluded on March 11, 2011. There were no rule violations associated
with 92630 however several rules were observed for 92236 linked to 92332 and 91785.
Page 21 of 21
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