Ridge Creek's Annual Inspection Report
Previous Inspections in this thread
http://fornits.com/wwf/viewtopic.php?p=227484#227484Georgia Department of Human Resources, Office of Regulatory Services
State Form Statement of Deficiencies and Plan of Correction
Inspection begin date
Inspection end date:8/2/2007
Personnel. Amended. SS=B290-2-7-.04(2)
This Requirement is not met as evidenced by: Based on record review and staff interview the camp failed to document job descriptions in 2 of 5 records. Findings Include:
1. Record review on August 2, 2007 of
2 (employee C and D) of 5 records revealed both employees did not have documentation of their current job description. 2. An interview conducted on August 2, 2007 at 2:30 PM with the Assistant Director revealed both employees should have had job descriptions in their file, but acknowledged the job descriptions were missing.
T 0401 290-2-7-.04(2) Personnel. Amended. SS=B
Outdoor Child Caring Programs shall have written job descriptions which specify what duties employees are expected to perform. A copy of the job descriptions shall be available to the employees and to the Department.
This Requirement is not met as evidenced by: Based on record review and staff interview the camp failed to document job descriptions in 2 of 5
records.[/i]
Findings Include:
1. Record review on August 2, 2007 of
2 (employee C and D) of 5 records revealed both employees did not have documentation of their current job description.
An interview conducted on August 2, 2007 at 2:30 PM with the Assistant Director revealed both employees should have had job descriptions in their file, but acknowledged the job descriptions were missing.
T 0419 06/25/2007 Personnel. Amended. SS=D290-2-7-.04(15)
This Requirement is not met as evidenced by: Based on record review and staff interview, the camp failed to document a complete ten year employment history, a satisfactory criminal records check, and educational qualifications in 1 of 5 records. Findings include:
1. Record review on August 2, 2007 of
1 (employee C) of 5 records revealed employee C's ten year employment history was missing the months, and there was no documentation of a criminal records check and educational qualifications.
2. During an interview conducted on August 2, 2007 at 2:30 PM with the Assistant Director, he/she acknowledged these items were missing and stated the Human Resource Department was in the process of gathering all missing documents.
T 0419 290-2-7-.04(15) Personnel. Amended. SS=D
The personal qualifications of employees shall be verified including a satisfactory criminal records check completed in accordance with O.C.G.A. Sec. 49-5-60. et seq. and a ten-year employment history. Verification of educational qualifications shall include documentation of a high school diploma or official transcripts from an accredited institution of higher learning.
This Requirement is not met as evidenced by: Based on record review and staff interview, the camp failed to document a complete ten year
employment history, a satisfactory criminal records check, and educational qualifications in 1 of 5 records. Findings include:
1. Record review on August 2, 2007 of
1 (employee C) of 5 records revealed employee C's ten year employment history was missing the months, and there was no documentation of a criminal records check and educational qualifications. 2. During an interview conducted on August 2, 2007 at 2:30 PM with the Assistant Director, he/she acknowledged these items were missing and stated the Human Resource Department was in the process of gathering all missing documents.
T 0420 06/25/2007 Personnel. Amended. SS=B290-2-7-.04(15)(a)
This Requirement is not met as evidenced by: Based on record review and staff interview, the camp failed to document three references in 2 of 3 records. Findings include:
1. Record review on August 2, 2007 of
2 (employee C and D) of 5 records revealed employee C had no references and employee D only had 2 references. 2. During an interview conducted on August 2, 2007 at 2:30 PM with the Assistant Director, he/she acknowledged the references were missing from the record and stated the Human Resource Department was in the process of gathering all missing documentation.
T 0420 290-2-7-.04(15)(a) Personnel. Amended. SS=B
At least three references shall be obtained for each potential employee prior to employment. Information obtained from the references shall be written and filed whether the interview is conducted in person or by telephone.
References should attest to the person’s capabilities of performing the duties for which they are employed and to the person’s suitability of working with the types of children served by the camp.
This Requirement is not met as evidenced by: Based on record review and staff interview, the camp failed to document three references in 2 of
3 records. Findings include:
1. Record review on August 2, 2007 of
2 (employee C and D) of 5 records revealed employee C had no references and employee D only had 2 references. 2. During an interview conducted on August 2, 2007 at 2:30 PM with the Assistant Director, he/she acknowledged the references were missing from the record and stated the Human Resource Department was in the process of gathering all missing documentation.
T 0421 06/25/2007 Personnel. Amended. SS=D290-2-7-.04(15)(b)
This Requirement is not met as evidenced by: Based on record review and staff interview, the camp failed to document a non-abuse statement in 1 of 5 records. Findings Include:
1. Record review on August 2, 2007 of
1 (employee D) of 5 records revealed the agency failed to document a non-abuse statement for employee D. 2. An interview conducted on August 2, 2007 at 2:30 PM with the Assistant Director revealed the Human Resource Department was in the process of gathering all missing documentation.
T 0421 290-2-7-.04(15)(b) Personnel. Amended. SS=D
Each employee shall submit an oral or written statement to the facility at the time of application that they have never been shown by credible evidence (such as a decision of a court or jury, or a department investigation or other reliable evidence) to have abused, neglected, sexually exploited, or deprived a child or adult or to have subjected any person to serious injury as a result of intentional or grossly serious injury as a result of intentional or grossly negligent misconduct.
This Requirement is not met as evidenced by: Based on record review and staff interview, the camp failed to document a non-abuse statement
in 1 of 5 records. Findings Include:
1. Record review on August 2, 2007 of
1 (employee D) of 5 records revealed the agency failed to document a non-abuse statement for employee D. 2. An interview conducted on August 2, 2007 at 2:30 PM with the Assistant Director revealed the Human Resource Department was in the process of gathering all missing documentation.
T 0423 06/25/2007 Personnel. Amended. SS=B290-2-7-.04(17)
This Requirement is not met as evidenced by: Based on record review and staff interview the camp failed to document training appropriately in 2 of 5 records. Findings Include:
1. Record review on August 2, 2007 of
2 (employee B and E) of 5 records revealed both employees had the required hours of training; however the agency failed to document the training appropriately with the name of the person who conducted the training.
2. An interview conducted on August 2, 2007 at 2:30 PM with the Assistant Director revealed the agency had been keeping a running list of training completed, but failed to keep individual certifications which included the name of the person who conducted the training.
T 0423 290-2-7-.04(17) Personnel. Amended. SS=B
In addition to the initial orientation, including training on the facility’s policies and procedures pertaining to behavior management techniques and emergency safety interventions, all staff working with campers shall receive annually at least 40 hours of in-service training related to children's service needs in a primitive environment. In-service training for staff working with campers shall be documented. This shall include the date, the subject, and name of the person who conducted the training.
This Requirement is not met as evidenced by: Based on record review and staff interview the camp failed to document training appropriately in
2 of 5 records.
Findings Include:
1. Record review on August 2, 2007 of
2 (employee B and E) of 5 records revealed both employees had the required hours of training; however the agency failed to document the training appropriately with the name of the person who conducted the training.
2. An interview conducted on August 2, 2007 at 2:30 PM with the Assistant Director revealed the agency had been keeping a running list of training completed, but failed to keep individual certifications which included the name of the person who conducted the training.
T 0428 06/25/2007 Personnel. Amended. SS=D290-2-7-.04(19)
This Requirement is not met as evidenced by: Based on record review and staff interview, the camp failed to document water safety and lifesaving techniques training in 1 of 5 records. Findings Include:
1. Record review on August 2, 2007 of
1 (employee D) of 5 records revealed the camp failed to document water safety and lifesaving technique training for employee D.
2. An interview conducted on August 2, 2007 at 2:30 PM with the Assistant Director revealed employee D completed the training in April, but the American Red Cross failed to send the cards and the information had to be resubmitted.
T 0428 290-2-7-.04(19) Personnel. Amended. SS=D
All child care staff shall have training by certified staff in water safety and lifesaving techniques.
This Requirement is not met as evidenced by: Based on record review and staff interview, the camp failed to document water safety and lifesaving techniques training in 1 of 5 records. Findings Include:
1. Record review on August 2, 2007 of
1 (employee D) of 5 records revealed the camp failed to document water safety and lifesaving technique training for employee D. 2. An interview conducted on August 2, 2007 at 2:30 PM with the Assistant Director revealed employee D completed the training in April, but the American Red Cross failed to send the cards and the information had to be resubmitted.
T 0436 06/25/2007 Personnel. Amended. SS=C290-2-7-.04(21)(f)
This Requirement is not met as evidenced by: Based on record review and staff interview, the camp failed to document annual performance reports in 3 of 5 records. Findings Include:
1. Record review on August 2, 2007 of
3 (employee A, B and E) of 5 records revealed employee A's last performance evaluation was dated 9/7/04, employee B's last performance evaluation was dated 2/20/06 and employee E's last performance evaluation was dated 12/20/05. 2. An interview conducted on August 2, 2007 at 2:30 PM with the Assistant Director revealed the Human Resource Department is in the process of updating all personnel records.
T 0436 290-2-7-.04(21)(f) Personnel. Amended. SS=C
[Personnel records] shall contain as a minimum the following information: ...
(f) Annual reports of performance, including all records of employee discipline arising from the inappropriate use of behavior management techniques and emergency safety interventions; …
This Requirement is not met as evidenced by: Based on record review and staff interview, the camp failed to document annual performance
reports in 3 of 5 records. Findings Include:
1. Record review on August 2, 2007 of
3 (employee A, B and E) of 5 records revealed employee A's last performance evaluation was dated 9/7/04, employee B's last performance evaluation was dated 2/20/06 and employee E's last performance evaluation was dated 12/20/05.
2. An interview conducted on August 2, 2007 at 2:30 PM with the Assistant Director revealed the Human Resource Department is in the process of updating all personnel records.
T 0511 06/25/2007 Admission and Intake Policies. Amended. SS=D290-2-7-.05(7)(b)
This Requirement is not met as evidenced by: Based on record review and staff interview, the camp failed to document a description of family relationships and the circumstances that make the placement necessary in 1 of 3 intake summaries.
Findings Include:
1. Record review on August 2, 2007 of
1 (camper #2) of 3 intake summaries revealed camper #2's intake summary had a section to describe family relationships and circumstances that make the placement necessary, however this section was not completed.
2. An interview conducted on August 2, 2007 at 2:30 PM with the therapist revealed she/he acknowledged this information was missing from the intake summary.
T 0511 290-2-7-.05(7)(b) Admission and Intake Policies. Amended. SS=D
The [intake] study shall include a summary of at least the following information: ...
(b) A description of family relationships and the circumstances that make the placement necessary; …
This Requirement is not met as evidenced by: Based on record review and staff interview, the camp failed to document a description of family
relationships and the circumstances that make the placement necessary in 1 of 3 intake summaries. Findings Include:
1. Record review on August 2, 2007 of
1 (camper #2) of 3 intake summaries revealed camper #2's intake summary had a section to describe family relationships and circumstances that make the placement necessary, however this section was not completed.
2. An interview conducted on August 2, 2007 at 2:30 PM with the therapist revealed she/he acknowledged this information was missing from the intake summary.
T 0513 06/25/2007 Admission and Intake Policies. Amended. SS=D290-2-7-.05(7)(d)
This Requirement is not met as evidenced by: Based on record review and staff interview, the camp failed to document the parent's expectation of placement in 1 of 3 intake summaries.
Findings Include:
1. Record review on August 2, 2007 of
1 (camper 3) of 3 intake summaries revealed the camp had a form to request information regarding parent's expectation of placement, however this section was not completed.
2. An interview conducted on August 2, 2007 at 2:30 PM with the therapist revealed he/ she acknowledged this information was missing from the intake summary.
T 0513 290-2-7-.05(7)(d) Admission and Intake Policies. Amended. SS=D
The [intake] study shall include a summary of at least the following information: ...
(d) The parents' or placement agency's expectation of placement; …
This Requirement is not met as evidenced by: Based on record review and staff interview, the camp failed to document the parent's expectation of placement in 1 of 3 intake summaries. Findings Include:
1. Record review on August 2, 2007 of
1 (camper 3) of 3 intake summaries revealed the camp had a form to request information regarding parent's expectation of placement, however this section was not completed.
2. An interview conducted on August 2, 2007 at 2:30 PM with the therapist revealed he/she acknowledged this information was missing from the intake summary.
T 0515 06/25/2007 Admission and Intake Policies. Amended. SS=D290-2-7-.05(7)(f)
This Requirement is not met as evidenced by: Based on record review and staff interview, the camp failed to document a description of the camper's personality, behavior and interests in 1 of 3 intake summaries.
Findings Include:
1. Record review conducted on August 2, 2007 of
1( camper #2) of 3 intake summaries revealed the camp had a section to document the camper's personality, behavior and interests, however this section was not completed.
2. An interview conducted on August 2, 2007 at 2:30 PM with the therapist revealed he/she acknowledged this information was missing from the intake summary
T 0515 290-2-7-.05(7)(f) Admission and Intake Policies. Amended. SS=D
The [intake] study shall include a summary of at least the following information: ...
(f) A description of the Camper's personality, behavior, and interests; …
This Requirement is not met as evidenced by: Based on record review and staff interview, the camp failed to document a description of the camper's personality, behavior and interests in 1 of 3 intake summaries.
Findings Include:
1. Record review conducted on August 2, 2007 of
1( camper #2) of 3 intake summaries revealed the camp had a section to document the camper's personality, behavior and interests, however this section was not completed. 2. An interview conducted on August 2, 2007 at 2:30 PM with the therapist revealed he/she acknowledged this information was missing from the intake summary.
T 0520 06/25/2007 Admission and Intake Policies. Amended. SS=D290-2-7-.05(7)(k)
This Requirement is not met as evidenced by: Based on record review and staff interview, the camp failed to document immediate and long-range goals of the placement in 1 of 3 intake summaries. Findings Include:
1. Record review on August 2, 2007 of
1 (camper #3) of 3 intake summaries revealed the camp had a section to be completed requiring documentation of immediate and long term goals, however this section was not completed. 2. An interview conducted on August 2, 2007 at 2:30 PM with the therapist revealed he/she acknowledged this information was missing from the intake summary
T 0520 290-2-7-.05(7)(k) Admission and Intake Policies. Amended. SS=D
The [intake] study shall include a summary of at least the following information: ...
(k) The immediate and long-range goals of placement; …
This Requirement is not met as evidenced by: Based on record review and staff interview, the camp failed to document immediate and long-range goals of the placement in 1 of 3 intake summaries.
Findings Include:
1. Record review on August 2, 2007 of
1 (camper #3) of 3 intake summaries revealed the camp had a section to be completed requiring documentation of immediate and long term goals, however this section was not completed.
2. An interview conducted on August 2, 2007 at 2:30 PM with the therapist revealed he/she acknowledged this information was missing from the intake summary
T 0534 06/25/2007 Admission and Intake Policies. Amended. SS=B290-2-7-.05(11)
This Requirement is not met as evidenced by: Based on record review and staff interview, the camp failed to document orientation for new campers in 2 of 3 records.
Findings Include:
1. Record review on August 2, 2007 of
2 (campers #2 and #3) of 3 resident's orientations revealed both campers had the documentation of orientation in their record; however both campers failed to sign the orientation form. 2. An interview conducted on August 2, 2007 at 2:30 PM with the therapist revealed he/she acknowledged the signatures were missing and stated this is usually completed before the campers go into the wilderness.
T 0534 290-2-7-.05(11) Admission and Intake Policies. Amended. SS=B
The Outdoor Child Caring Program shall provide orientation for new campers.This Requirement is not met as evidenced by: Based on record review and staff interview, the camp failed to document orientation for new campers in 2 of 3 records.
Findings Include:
1. Record review on August 2, 2007 of
2 (campers #2 and #3) of 3 resident's orientations revealed both campers had the documentation of orientation in their record; however both campers failed to sign the orientation form.
2. An interview conducted on August 2, 2007 at 2:30 PM with the therapist revealed he/she acknowledged the signatures were missing and stated this is usually completed before the campers go into the wilderness.
T 0919 06/25/2007 Emergency Safety Interventions. SS=D290-2-7-.09(2)(c)1.
This Requirement is not met as evidenced by: Based on record review and staff interview, the camp failed to document an assessment at admission to indicate that there were no medical issues that would be incompatible with the appropriate use of emergency safety interventions in 1 of 3 records.
Findings Include:
1. Record review on August 2, 2007 of
1 (camper #3) of 3 records revealed camper #3 had a physical documented and the form requested information regarding any issues surrounding emergency safety interventions, however the doctor did not sign this form.
2. During an interview conducted on August 2, 2007 at 2:30 PM with the therapist he/she acknowledged the doctor's signature was missing, but added the physical stated, "see attached papers" which had the doctor's signature.
T 0919 290-2-7-.09(2)(c)1. Emergency Safety Interventions. SS=D
Emergency safety interventions policies and procedures shall include:
1. Provisions for the documentation of an assessment at admission and at each annual exam by the camper’s physician, a physician’s assistant, or a registered nurse with advanced training working under the direction of a
physician, or a public health department that states there are no medical issues that would be incompatible with the appropriate use of emergency safety interventions on that camper. Such assessment and documentation must be re-evaluated following any significant change in the camper's medical condition; ...
This Requirement is not met as evidenced by: Based on record review and staff interview, the camp failed to document an assessment at admission to indicate that there were no medical issues that would be incompatible with the appropriate use of emergency safety interventions in 1 of 3 records.
Findings Include:
1. Record review on August 2, 2007 of
1 (camper #3) of 3 records revealed camper #3 had a physical documented and the form requested information regarding any issues surrounding emergency safety interventions, however the doctor did not sign this form.
2. During an interview conducted on August 2, 2007 at 2:30 PM with the therapist he/she acknowledged the doctor's signature was missing, but added the physical stated, "see attached papers" which had the doctor's signature.
T 9999 06/25/2007 Closing Comments. An exit conference was conducted while on site. A preliminary report of the findings was left on site on this date and a final version of the findings will be mailed to the facility upon completion.
A plan of correction in response to the preliminary findings was due to the surveyor by August 16, 2007.
T 9999 Closing Comments. An exit conference was conducted while on site. A preliminary report of the findings was left on site on this date and a final version of the findings will be mailed to the facility upon completion.
A plan of correction in response to the preliminary findings was due to the surveyor by August 16, 2007.
