PATRICIA A. ROGERS HOUR TINO SQUARE: - - - 2! I NORTH 2- CITY, OK 7330.! I03 (403% 2 FAX (405) 2373-0430 pat com east-1f tram January 15, 2016 Via USPS Express Mail Termination Docket ierk Oklahoma Health Care Authority PO. Drawer 18497 Oklahoma City, OK 73154-0497 Re: Shadow Mountain Behavioral Health System, LLC REQUEST TO REVIEW YOUR DECISION TO TERMINATE PROVIDER CONTRACTS _and Dear Ma?am or Sir: We represent Shadow Mountain Behavioral Health System, LLC ("Shadow Mountain?). On January 4, 2016, Shadow Mountain received your letter dated December 30, 2015 providing that the Oklahoma Health Care Authority intends to terminate the above-referenced contracts. We are hereby requesting a review prior to such termination in accordance with OAC Shadow Mountain has taken prompt corrective action with respect to each of the ?ndings of OHCA during its announced and unannounced onsite reviews in 2015 and in previous years. We disagree with decision to send a ?Notice of Intent to Terminate? our acute care and threshold unit contracts because Shadow Mountain is in compliance with reguiatory standards. Further, these contracts are not subject to the CAP that was put in place in August, 2015. In support of our position that OHCA should not terminate the above~referenced contracts. we submit that Shadow Mountain has taken the following corrective actions during 2015: I As of March, 2015, for each of the Threshold and South ?houses? or units, Shadow Mountain has added 1.4 FT of mental health technicians to ensure that it satis?es the required staf?ng ratios. In April, 2015, Shadow Mountain renovated the nursing station of the Threshold Unit so that it has full view and is accessible to all patient care areas at all times. JAN 1 9 20:5 OHCA LEGAL DIVISION A ?7w: Trig; tux: Nit 3.14.: E: 51,.1 Ix.) In April, 2015, Shadow Mountain renovated the nursing station of South residential treatment center so that it has full view and is accessible to patient care areas at all times. As of April, 2015, Shadow Mountain has implemented procedures so that there are separate and distinct professional staff for the Acute and PRTF units. As of August, 2015, Shadow Mountain hired a full-time ?oat RN to pass medications. This is an RN position who is not assigned to a speci?c acute unit. The float RN is available to provide coverage for seclusion and restraints, admissions, or other RN duties that might be needed. As of October, 2015, Shadow Mountain purchased the software program ?ShiftHound? which allows the organization to manage staf?ng ratios on a 24/7 basis. Please see Exhibit A providing evidence of the use of ShiftHound. The 2W residential treatment unit, a total of 24 beds, meets or exceeds the staffing coverage ratio requirements of one tech per 8 patients during hours of sleep and one tech per 6 patients during waking hours. Shadow Mountain continuously advertises for mental health technician positions and RNs so that it always has a pool of applicants to hire from and keep core staff in place. Please see Exhibit for samples of advertisements that Shadow Mountain has used. Shadow Mountain advertises on the following media: iHeartRadio, Tulsa World, Monstercorn, HealthECareers.com, The Job Guide, Indeedcom ?shes Shadow Mountain?s website and posts what it has listed; local college job boards, NE Arkansas newspapers, Arthur L. Davis Nursing Quarterly Publication, and America?s Job Exchange. Shadow Mountain has a PRN pool of RNs, including four RNs that are agency nurses who have been undergone the State?s requirements for ?ngerprinting and background checks. Shadow Mountain no longer has an issue if the scheduled RN is on PTO. Attached as Exhibit is the current PRN ?oat pool including RNs and LPNs. Shadow Mountain conducts new staff orientation weekly - new staff members are trained right away and there is no delay in assigning staff to units. Please see Exhibit for Shadow Mountain?s new staff training schedule. As of March, 2015, Shadow Mountain hired an acute care coordinator whose primary reSponsibility is staf?ng and maintaining the required staffing ratios. As of December, 2015, Shadow Mountain hired a PRTF coordinator whose primary responsibility is staffing and maintaining the required staf?ng ratios. Upon receipt of letter of August 19, 2015, Shadow Mountain has implemented the Corrective Action Plan for Attached as Exhibit are Monitoring Summary reports for 05/13/2015, 05/19 - 21/2015, 06/16/2015, 06/25/2015 and 10/29/205 showing no noncompliance issues related to Shadow Mountain's staf?ng or ?ndings. Shadow Mountain has spent approximately $250,000 in making the above-described renovations and staf?ng changes during 2015. Shadow Mountain has been recognized by The Joint Commission as Top Performer on Key Quality Measures for the fourth year in a row. Additionally, with respect to ?ndings set forth in your December 30, 2015 letter, we wish to clarify the following: During none of the OHCA or OKDHS on~site reviews, did either or OKDHS raise an actual patient or resident safety issue. During the February 12, 2015 on?site review by OHCA, concluded that the staf?ng ratio on one RTC unit was 1:22. At the point in time that OHCA was measuring staf?ng, two staff members were just adjacent to the unit in a room calming down an adolescent who was having a dif?cult time. The two staff members were otherwise available. The staff members were able to immediately respond to any other resident matters. During the August 27, 2015 on-site review by OHCA, at the time that OHCA measured staf?ng, the RN for the acute adolescent had left the unit to get her dinner in the cafeteria and was available at all times by radio, and immediately came back to the unit when called. OHCA concluded that there was no RN on the unit. During the August 27, 2015 on-site review by OHCA, at the time that OHCA measured staf?ng, the RN for the pediatric acute unit was in the hall with a patient, just a few steps away from the unit. OHCA concluded that there was no RN on the unit. With respect to the paragraph 4 of the CAP, Shadow Mountain complies with OHCA reporting requirements. Regarding paragraph 6 of the CAP, Shadow Mountain requires that employees be escorted by Shadow Mountain staff, which is in the best interests of all individuals involved. Shadow Mountain cannot ailow unaccompanied OHCA staff, who are unknown to Shadow Mountain employees, to walk through the hospital and units. DHS licensing requirements mandate background checks and ?ngerprints on any person who is left alone with a patient. Unaccompanied OHCA employees are at risk for assault and have not received appropriate training, which represents a substantial liability for Shadow Mountain. The safety of patients, visitors and staff is paramount. Shadow Mountain will provide staiT to safely escort OHCA personnel around the hospital as quickly as possible, remain at distances and allow them to have private conversations with staff, and have access to all areas of the hospital. Generally, the hospital does not have additional staff during the evening and night shifts to provide the necessary escorts. CC: Shadow Mountain made a substantial capital investment and developed the Riverside specialized PRTI: in response to the state?s need programs for adolescents with developmental delays, reactive attachment issues, and autism. Prior to the opening ell? Riverside OKDHS lied to place such adolescents Out of" state for treatment. Ol-lCA7s finding that staffing ratios ?were not consistently met? and ?not always 21 RN solely assigned? are isolated incidents that are not. indicative of the Riverside program. To obtain clarification of the staf?ng issue, $hedow Mountain initiated and held an in? person meeting with Jennifer King of and ?l?raylor Reines, OKDtt-t'lviSAS; Medicaid director; on August 23, 201:3 to obtain further guidance as to these. matters. Beth Ms. King and Mr. Raines stated that the de?nition oft-gt ?unit? was unclear and tits! they would take the issue back to their respective agencies. also note that a specie-zit}: unit must have 21 RN accessible to it, but is not required to have 3 RN on the unit, in. conclusion, Shadow Mountain has implemented signi?cant changes so that it can centinuousiy meet staffing requirements in each of" its units. Shadow Mountain provides quality and much needed services for the child and adolescent. Oklahoma Medicaid population. At no time did. OHCA nor OKDHS voice any patient or resident safety concern during its visits. Based on the foregoing, we respectfully request that reconsider its notice of intent to terminate Shadow Mountain?s SoelterCz-zre contracts. Please. contact me, Patricia Rogers. at 405-552?2233 ii?yott have any questiorts. Signed. Patricia A. Rogers and try I 0 Michael Kistler CEO Sliedew Mountain Behavioral Health System Becki Burton Deputy General Counsel Via Regular Mail EXHIBITA baiiy Staf?ng Report 01114116 Thu'r'sday Day 1 est ECT House Super Amber, W. Admin Admin Adrianne, RN ITS Thresh?ld - MHT MHT Daily Staffing Report 01114116 Thursday Evening 1 est 3 West Available Staff MHT MHT RN House Super ITS Ml-iT MHT Girls Feds MHT MHT Threshold Daily Staffing Report 01/14116 Thursday Night 1 West 3 West Available Staff RN MHT House Super ITS MHT SH Girls SH Feds MHT MHT Nurse MHT Threshold Threshold; MHT MHT Nurse MHT EXHIBIT SHADOW MOUNTAIN BEHAVIORAL HEAITH SYSTEM 11 1] Mental-Health-Techsr? Nurses?SrThe-rap-istsm Full-.Time- an?- PBN- po?ttions? availabla' at' Sheridan:- ExpErience- working- with-childrianfacfolescents- is-a-plus." N?s- -- curren-t- OK- ic nse- - d- a d? . Therapists: -- current- OK- License- or- be- License- Eligible- Tl; 5252-5.-Sherida 1013' Es??m' PIace,-Tulsa, 51] TI 1E allucurrent-openings?l TE SM BHS- offers- a - com plete' bene?fits'pa ckage-for-ful l-tim - Arthur Davis: Nursing Pay copkg@u 4133' 'staff'inQILIding-am 401k I . $2 .us?for Full-Tim BN3 $1 We also use the NE Arkansas Newspapers, Arthur Davis Nursing Quarterly Publication, America?s Job Exchange. Tulsa World: semanw HDUHMN 3433*! Emmi 53-593" $2508 SignnOn Bonus for RN's New Nursing Pay And Inpatient Therapists! - Current 0K license in good standing. In 6116!? Them - Current OK license or be License Eligible (Under SUpervisionii LPC. LMFT. LCSW. or LBP Applications May be Submitted in Person: 6262 S. Sheridan or 1013 E. 66th Place, Tulsa, OK 74136.. . Or by E?mailing mm to receive an electron is: a?plicetion. Visit; s.com!careers To View ail curreni openings. offers a complete benefits package for full~time stat-f includin medical dental vision 40m and PTO. EXHIBIT FLOAT POOL PRN-RN Jennifer A ca" PRN-LPN Brenda Williams PRN-RPN Rachel Touma Ca" PRN LPN Tasha Hollie PRN-LPN Ma Street Karen Williams- ers PRN-LPN Jeri Van Dusen PEN-RN Nichole ht ECT MONMEDIRI PRN-LPN Yolanda Ware PRN-RN Henrietta A PRN.RN PRN-RN Mavis Asare Adrianne Miller ECT PRN-RN Candice Rush Nicole Cartwri ht PRN-RN Norma Aurthur PRN-RN PRN-LPN Jailcia PRN-RH PRN-LPN Diane Austin PRN-LPN PRN-RN Teresa Williams amen Charla Manta ue Jeanlouls PRN-RN Lee PRN-LPN obl w. PRN-RN Desiree Jenkins PRN-RN Tlffan Cones PRN-RN Suzle PRN-RN Pam PRN-LPN PRN-RN Desiree Jenkins PRN-RN Patricia Beal PRN-RN Amber Price PRN-RN Eastman Hol PRN-LPN Lin Weems PRN-RN Jeanne Bennett PRN-RN Hurst PRN-RN Updated 1/13/2016 PRN-LPN EXHIBIT This training is conducted every week. We did not have training on the week of Thanksgiving (Nov. 23- 27) and Christmas (Dec. 2145). We plan on having this same schedule for the 2016 year. Mondays, Day 1 Diversity Sexual Harrassrnent Time Clocks/Payroll HIPAA Facilitating Rehab Groups Corporate Compliance: Code of Conduct Circumstantial Life Changes RIGHT Suicide Prevention OSHA Tuesdays, Day 2 Trauma informed Care Mental Health Disorders Wednesdays, Day 3 Handle with Care Vital Signs injury Prevention Thursdays, Day 4 Patient Supervision Policy 8! Procedures Dyadic Developmental Service Excellence Behavioral Precautions Risk Management Driver?s Safety Documentation Fridays, Day 5 CPR/First Aid Therapeutic Boundaries infection Control Patient Advocacy EXHIBIT Monitoring Summary Resident Fiie Review Hill 0K DHS 1X1 I LllN('i mum {mum I Facilin Name License Number Subtype Visit Type Purpose of Visit Visii Date Visit Time SHADOW MOUNTAIN K85-0000226 RGSiden?iBI Fuli Periodic Trcaimenl '1 0l29/2015 9:30 AM Owner Name Case Status Perm! Expiration Total :1 of Flies Reviewed SHADOW MOUNTAIN Licensed 8 BEHAVIORAL HEALTH SYSTEM Director Name Licensed Capacity Total ResidentCansus ToialSiaff MFP Kisiier Mike 126 102 Employed 250 8 Locailon Address Gilt} State 6262 S. SHERIDAN LSA Oklahoma 7 133 Mailing Address City State Zip Discussion AREA OF NO IMMUNINZATOINS RECORDS OR DOCUMENTED REQUESTED IN FILE. AREA {gram 5. NO iN NQAREASOF - NO AREAS OF NON-COMPUANCE FOUND IN THIS FILE TODAY. Revised November 14, 2012 O7 LCUSEE (OCC-SS) CC MASS Page Page 1 of 2 Resident File Review Monitoring Summary Facility Name SHADOW MOUNTAIN License Number K850000226 Visit Type Fuii Subtype Residential . mn? Purpose of Visit Periodic Visit Date 10/29/2015 I - .i't?es?icieni Name it'teqnlre'ment and Description Noncompi-iencetNC) Obsewed ?Correct I bare - the resident's immunization record. medicat and dental history. including any current medical problems; . 133 119:3'd,evetoping.ihei I service - NO RECORDS FILE 0R RECOMMENDATIONS OF REQUESTED RECORDS Signature-on treat: immunizations be requested or documented at time of admissions 1 0/29/1201 5 .. . . . . and maintain; .- 4012912015 Based on today?s visit, the items marked identity areas of non-compiiance with the Licensing Requirements for Residential Child Care Facilities and must be corrected. These andror iulure violations oi licensing requirements may result in the revocation ot your license or the issuance of an emergency order of closure. (mt Signed Director or Stet! in Charge Revised November 14, 2012 Wt?w Licensing stail (0:059) CCMASS WINGSS Page 2 Page 2 ot2 inIHiA Monitoring Summary OKDHS Residential turn! 1 hit"! FaciiDate Visit Time SHA oa MOUNTAIN gesl?c?l?imal Fuii $353363 5? 1&2912015 9:30 AM Owner Name ?Game? Case Status Petmit Expiration SHADOW MOUNTAIN BEHAVIORAL HEALTH SYSTEM Licensed Director trifensed Capacity Total Resident Census Tote! Staff Emptoyed MFP Make 6 102 250 3 i 135%? $51.89. W133 Mailing Address City State Zip Health Inspection Required Health Inspection Date Fire Inspection Date Environmental Inspection Date to be paid for by Yes #2112015 10101I2015 Residents PresentlDirect Care Staff Shelters i - -. Treatment - 102 residents With-32 direct care and Petsonnel ?le review Resident tile review Policy review Revised November 14, 2012 UYLCOSBE (000-58) CCMASS Page Page 1 of3 Monitoring Report RooidentIaI Care Facility Faculty Name License. Number Sublypo Typo ofVisIt Purpose Date SHADOW MOUNTAIN ICES-0000226 gesitlentiai Full Periodic 1012912015 9:30 AM Corrections of non-compliance from previous visit: UNANNOUNCED VISIT. MONITORING VISIT: No areas of non-compiianoe found during this visit. RESIDENT FILE REVIEW: 8 ?les reviewed, areas of nomoompllonce found this visit Immunizations and signatures. PERSONNEL FILE REVIEW: Ail new ompioyee?s were viewed on paper form and copy left with facility. No areas of non-oompiianoe found on personnel ?ies today. R?duireni?ht ati'cf? Desorip?tlon Based on today's vioit. tho Items matked identify areas of norz~ooraniame wilh the Licensing Requirements to: Residenliai Child Care and must be corrected. THESE: oodlor fulwe violations of licensing requirements may resu? in the of your license or Ihe Issuance of an emorgenoy order of down: Signed Ulteotor or Stafi In Change Licensing slatf Wilness Revised Novomber14-, 2012 07L0058E (00058) CCMASS Page 2' Page 2 013 Monitoring Report - Residential Child Care Facility Facility Name License Number Subtype Type of Visit Purpose of Visit Visit Date Visit Time SHADOW K850000226 ?esifteniiai Full Periodic 10i2912015 9:30 AM ?i 1 i - hire date was prior to visit date. otherwise. Discussed that at last visit about all new employees must foiiow the licensing requirements for new hires. Also. discussed it again today with Mt?. Kistter because staff are being missed when reviewing files. What happens is the facility ask about what was the date of the last visit and then will bring files from that date on and the peopie that were in orientation are being missed because there actuat i attest that sit items on the checklists were monitored and found to be in oompiiance at the time of the monitoring visit unless marked Revised November 14, 2012 oneness (coo?53) CCMASS Page 3 of 3 Elli! Monitoring Summary Residential - runner; . - Ll 1: Sub Vls't Pu fVlsit Visit Vls'l Tl ?esl?itial Paa'?a pa Perriijgi?t? 5125123195 9:36 Owner Name ?Game? Case Status Permit Expiration SHADOW MOUNTAIN BEHAVIORAL HEALTH SYSTEM Licensed Director Capacity Iota] Resident Canoes Total Staff Employed MFP KlSilBl? Mike 1 04 A 248 3 $12?th ??isxx El?le?ihoma 53?133 Malling Address City Slate Zip Health Inspeclion Required Health lnspection Date Fire Inspection Date Environmental Inspeclion Date to be paid for by 112112015 911012014 Residents PresentlDirect Care Staff Shelters Type?) I I Reeideots Staff-7' Age Group - Residents. Sleff?f Personnel ?le review v' Resident file review Policy {eview Revised November 14, 2012 OYLCOSBE (000-58) CCMASS Page 1 Page 1 ol 3 Monitaring Report Residential Child Care Facility Name License Number Subtype Type of Visit Purpose of Visit Visit Date Vlsit Time SHADOW MOUNTAIN K853030225 gisififntiai Partial Periodic 6/2512015 9:30 AM Correctians of non~compiianoe from previous visit: gDiSdussiion-rri . -. -. UNANNOUNCEB VISIT: MONITORING VISIT: A tuii monitoring report was completed on OGIGGIIS atong with a complaint RESIDENT FILE 9 FILES REVIEW. Area of non?compiiance were no Immunization recerds. PERSONNEL FILE REVIEW: Campieted cm paper form, see tite cabinet and trail a copy with facility. No areas of non-compliance found during this visit. I Noncompliance (NC) Observe-d I Plan To Correct I Date NR8 R?qtiirenie-nt sat-1d Description iance wilt} the arranging Requirements for Residential Child Care and Based on today?s visit, the items marked identify areas of non-crimp: ation of your iicense car the issuance of an must be corrected These artdfur future vialaticms a! Roaming requirements may result in the warm?: emergency order of cinema (Mam Signed {Erector 0r Stat! In Charge Licensing siati Witness 07L0058E (00058) CCMASS Page 2 Revlsed November 14. 2012 Paga 2 0t 3 Monitoring Report Residential Child Care acuity Facility Name License Number Subtype Type of Visit Purpose of Visit Visit Date Visit Time SHADOW MOUNTAIN K850000226 Eisjfientif? Partial Periodic 6I2512015 9:30 AM ?Dlscussion' DISCUSSED ABOUT ALL NEW HIRES MUST FOLLOW NEW FINGERPRINT PROCESS AS OF THIS DATE. 1 ATTEST THAT ALL ON THE CHECKLIST WERE MONITORED AND FOUND TO BE IN COMPLIANCE AT THE TIME OF THE MONITORING UNLESS MARKED OTHERWBE. Revised November 14. 2012 (mousse (coo?53) CCMASS Page 3 013 Monitoring Summary Resident File Review nummu OKDHS lXL?izllek'L Facility Name License Number Subtype Visll Putpose ol Visit \?sii Dale Visit Time SHADOW MOUNTAIN K850000226 Residen?al Full Periodic TIealmeni 6/2512015 9:30 AM Owner Na ma Case Status Permit ExplIatlon Total it of Flies Reviewed SHADOW MOUNTAIN Licensed BEHAVIORAL HEALTH SYSTEM Director Name Licensed Capacity Total Resident Census Total Staff MFP KIslier MM 114 Employed 3 Location Address C18 State 22) 6262 S. SHERIDAN LSA Oklahoma 7 133 Malling City Slate Zip NO AREAS OF NON-COMPLIANCE FOUND 1N THIS FILE TODAY. NOARIEAS OF FOUND THIS FILE TODAY. NO AREAS OF NON-COMPLIANCE FOUND iN THIS FILE TODAY. AREA OF 0R REQUESTED IMMUNIZATION RECORDS. RECORDS. N0 AREAS OF NON-COMPLIANCEFOUND IN THIS TODAY. MREAS OF FOUND IN FILE TODAY. Revised November 14. 2012 07LC059E (0:059) CCMASS Page 1 Page 1 ol 2 Resident File Review Monitoring Summary Facility Name License Number Subtype Purpose of Visit VisltDate Visit Time SHADOW MOUNTAIN K050000220 Fuii Periodic 0/25/2015 9:Resldent Requirementand Noncompllance (NC) Observed Plan To Correct Date Name Description - NO OF Will make sure all immunization records the resident's IMMUNIZATION RECORDS OR are requested or received at immunization SHOWING REQUESTED admissions. record. medical and dental history. Inciudlng any current 7 7 ., ?.0070?, A Based on today's visit, the items walked identify means of noncompliance will; the Licensing Requilemants for Residential Child Care Facilities and must be couected. These antifo: lulure violations oi licensing tequIIementa may {esull In the invocation oi your license or the Issuance of un emaigency Gide! of ciosmo. . gt?i?m?z Signed Director or Stall In Charge Licensing stall Witness Revised November 14, 2012 (DEC-59) page 3? Page 2 o! 2 ms! Monitoring Summary Residential V'itl sa?kboa SMOUNTAIN gtsi?tugz F?srl artists Owner Name l?ea?me'? Case Status Permit Expiration SHADOW MOUNTAIN BEHAVIORAL HEALTH SYSTEM Llcensed ?ag?mke trlfaansed Capacity ggtat Resident Census Total Staff Employed i . 135%? g. ?isrt gl?t??homa it? 33 MatIIng Address City State Zip Health Inspection Required Health Inspection Date Fire Inapsction Date Environmental Inspection Date to be paid for by Yes 112112015 Sim/2014 Residents PresentlDirect Care Staff Shelters . Type?. . Residents :i-starf: 3 A997 Group. i -. a Residents Staff. Treatment I I I 91 otters?! residents with 20' I I I I direct care staff Personnel ?ts review Resident file review Policy review Revised November 14. 2012 07L0058E (00058) CCMASS Page 1 Page?t of2 Monitoring Report - Residential Child Care Facility Facility Name License Number Subtype Type of Visit Purpose of Visit Visit Date Visit Time SHADOW MOUNTAIN K850000226 ?esidentiat Fuli Complaint 10:00 AM Corrections of non-compliance from previous visit: DISCUSSIOH . . . -- . - Felt visit compteied at this compiaint visit. Complaint visit allegations: t. Physieei facility non-comptiance-no doors on bedrooms, screws sticking out doorways. and paneling coming off. 2. Adolescence unit understaffed with 1 staff with 14 residents and no nurse. No non-complianoes found during this visit. Complaint allegations unsubstantiated. .. . .. Noncompliance (NC) Observed Pian To Correct Date NRS I ?Requirement and Description Based on today's visit, the items marked identify areas of non-compliance with the Licensing Requirements for Residentiai Child Care Fecii?rties and must be corrected. These and/or future violations of licensing requirements may resutt in the revocation or your license or the issuance of an emergency order of ctosure. WW Director or Staff in Charge ?rth Signed Licensing etatt Witness Revised November 14. 2012 (DOC-58) CCMASS Page 2 Page 2 at 2 3.0.333?; Monitoring Summary is; Residential Facililv Name License Number Sub; V'lsil 9 Put asepf Visit Visit Dal?: Visit Time SHADOW MOUNTAIN Res: guttal Full ?3 Congplalnt sue/201?s 10:00 AM Owner Name? ?931mg?! Cass Siatus Permit Expiration SHADOW MOUNTAEN BEHAVIORAL HEALTH SYSTEM Licensed Director Licensed Capacity Total Resident Census Total Stall? MFP Klslier Mike 114 $555 gf?sHE??l?AN TLFESA k?la oma ?llss Mailing Address City State Zip Health inspection Required Health inspection Date Fits lnspectmn Date Environmentai Impairth Date to be paid for by Yes 1/21/2015 53/109014 Residents PresentlDirect Care Staff Shelters Type Residents Staff Age Group ReSidems Staff Pel'sonnsl ?le review Revised November 14. 2012 91 overall residents with 20 direct says staff Resident file review Policy revzew (Oil's-58) CCMASS Page 5 Page 1 cl? Monitoring Report Residential Chitd Care Name SHADOW License Number Subtype Type 0t Visit Purpose of Visit Visit Date Visit Time K850000226 Residential Full iComplaint 6/16/2015 $10130 AM {l Corrections of non~comptia nee from previous visit Discussion Futl visit completed Tat this visit. Co'mptaint viSit allegations: 1. Physicat non-?cmpliance?o don-rs on b?dr?dms. Screws sticking out doorways, and paneting coming off. 2. Adotescence unit understaffed with 1 staff with 14 residents and no nurse. No non?comptiances found during this visit. Comptaint ailegations unsubstantiated. Planet-Correction . . Requirement and Noncompiiance (NC) Observed Pian To Correct Date NR8 Description i 83346.2(} an tracings. WSIL the stems mark-ed identify arena at i?E?t?t?CO?ig?iaiitTE-S min the Fteqtnramarim Rte-ssz'tezttia? ?rm Care Fansisttes. and must be corrected These midst}! Mitre 22f matizrements may fez-suit that of you; iazzense {if the mi an eimsgenq sitter {ii Sig]ij gimme; {If Staff in Chatge Liazenseirig; staff Witt'iess CCMASS Reviged November 2012 Page 2. Pagezd? OKLAHOMA DEPARTMENT OF HUMAN SERVICES CHILD WELFARE SERVICES CONTRACT PERFORMANCE REVIEW Site Reviewed: Provider: Shadow Mountain Behavioral Health System Shadow Mountain Behavioral Health System Contact: Mike Kistler, CEO Jolene Ring, COO Address: 6262 S. Sheridan 6262 S. Sheridan CityIState/Zip: Tulsa, OK 74133-4099 Tulsa, OK 74133-4099 Type of Services Provided: Begin Date of Visit: End Date of Visit: 05/21/2015 Purpose of Visit: Annual Review Participants on Review Team: Linda S. Moss, Programs Field Representative, Stacey Mayle, Programs Field Representative, Miner, Programs Manager, Sources of Information Namber of child records reviewed: 5 Number of children interviewed: 5 Number of discharged records reviewed: 5 Number of employees interviewed: 21 REPORT OVERVIEW This report summarizes ?ndings of a performance review conducted by representatives of the DHS. The review evaluated conformance with requirements of the agreement to provide services to children and families. Performance was assessed through review of records as well as interviews with service recipients and staff. The report identi?es areas that did not conform to agreement expectations. Appeals: The agency may provide additional information to the Review Team during the exit Conference. The team will review the information and determine if it af?rms that practices are consistent with program requirements. Further consideration may be requested by mailing a written appeal within one week of the exit to: Jimmy Arias, Lead Team Member, Specialized Placements and Partnerships Unit, PO Box 25352, OKC, OK, 73125. Reaponse to Findings: If resolution of each identi?ed concem will be achieved within two months of the exit, it is not necessary for the provider to submit a plan of corrective actions. Any projected resolution date beyond two months of the exit must be accompanied by justi?cation. Approval of extended resolution dates occurs only upon evidence that extensive change in provider management systems or extensive expenditures is essential to the resolution of the problem. The justi?cation must include plans and time frames to implement incremental changes necessary to achieve conformance with rules. The completed document and attachments are mailed within two weeks to: Dawn Carson, Field Manager, PO Box 25352, Oklahoma City, OK 73125. The written response must be ?led regardless of the status of any request for appeal. Failure to submit a response within two weeks of the exit conference results in an expectation that all de?ciencies be resolved within two months of the exit conference. Follow-up: A focused review will be conducted to assess the resolution of all identi?ed areas of non- conformance. This follow-up occurs after approved resolution dates. SUMMARY OF FINDINGS No Findings Outcomes No Findings - Shadow Mountain had their ?rst resident to graduate from high school this week which was a child in DHS custody. Shadow Mountain staff held a graduation ceremony and a reception to celebrate the achievement of this young lady. - Remodeling and expansion efforts have been completed. Case ?les continue to be organized and easy to read. 10 7%JJ/7ws HIV Report prepared by: Linda 8. Moss Date CFSD Representative Report received by: Jolene Ring This is to acknowledge receipt of this report on results of the perfonnmice review and attendant due dates. Acknowledgment of receipt does not imply agreement with information contained within the report. Resolution of all conditions resulting in OR A request for an extended resolution date, ?ndings ofnon-compliance will be achieved by including plans and time frames to achieve July 21, 2015. conformance, will be submitted to Dawn Carson by June 2015. Ptiivider Representatii/e Date Provider Representative Date Distribution List Miner, CWS, CPR Dawn Carson, CWS, Specialized Placement and Partnerships Ali Tipton, Liaison, CWS, Specialized Placement and Partnerships Child Placing Agency Licensing, Office of Child Care Of?ce of Juvenile System Oversight, Oklahoma Commission on Children and Youth Oklahoma Health Care Authority Lo.) .3 OKLAHOMA DEPARTMENT OF HUMAN 5%;gmgm . .- y: Monitaring Summary i . 3 Residential .- a a ?ensu Imber i . kill?! I I I Bes?'?nna: pa?'iaawe gFilim?JE V's" Sgt/33% Owner Name ?931mm? Case Siatus Permit Expiration SHADOW MOUNTAIN BEHAVIORAL HEALTH SYSTEM Licensed Dir ctar Licensed Ca acit Totai?esid (C i Kis?ef Mike ?4 ?102 00 00503 3 Sta? Empioyed a i - ??ioma 775': 33 Mailing Address City State Zip Health. Inspection Required Health inspection Date Fire Inspecticn Date Environmentai Inspection Date to be paid for by yes 1/21/2015 900/2014 2 . 2 Residents Presenunirect Care Staff Shelters I . Ty?e- .. - Residents :Staff; . 'IAge Group . 'Resfident55: Staff-J- Treaanen: 102 residents-Mm 19 direct care i *4 Personnel ?le review Resident file review Poiicy review Revised November 14, 2812 GHQ-058E CCMASS Page 5 i Monitoring Report - Realdential Child Care Faciiny Facility Name License Number Subtype Type of Visit Purpose of Visit Visit Date Visit Time SHADOW MOUNTAIN K850000226 Residential Partial! Fonch Up 5/13/2015 51125 PM IfEaimcn?I i 0f non-complia nee from previous visit- 'Diswssi??FOLLOW UP VISIT 550R UNDERSTAFFING. NO AREAS OF NON-COMPLIANCE FOUNO OURI NG THIS VISIT. DISCUSSED MIKE WERE SEVERAL STAFF THAT WERE SITTING THE PARKING LOT WHEN LICENSING AR Requirement and Noncompiiance Observed Plan To Correct Date NR8 Description I -mm??wm ?m.u ?I-qu Based an Imay?s the dams masked Icemafw; areas 0? min the Licensing Rezuarenzemg I?m Reside-mug: {3th must be corrected These 30:00.: future: viraiatimns 0f Eisenswg requiremenis may realm the revocatmn Of got, emergency omier 0? 0:05:09. S?g?ed 1 000001: or Staff En Charge )qg/I LicenSirIg start warms 07LOOSSE (000-50) COMASS wal?Q'nnWI1 ?Hutu-W mm Care Fac??ies am Emma Or {he issuance of an Revised November 14? 2012 page 2 (ha??u-a