Report of Inspection

at the request of the

Board of Private Alternative Adolescent Residential Programs

Program: Wood Creek Academy, 
76 Tanager Lane
Thompson Falls MT

Inspector: T.J. Hunt
Jody Dalbec
Date of Inspection: August 15, 2017

Site Inspection:

[Note: This was an unannounced site inspection conducted in response to Complaint 

1.


I [3 Plan of operation as described in application fits with the appearance of the operation
as laid out during walk through.

Comments: Wood Creek is a 12-month residential program for boys. No changes to operation.

2.

I The number of program participants is consistent with information submitted with
application and provided by Administrator.

Comments: At the time of the inspection, Wood Creek had 19 participants. This is consistent with
the program?s 2017 Renewal.

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Premise does not contain an area that could be used for corporal punishment, isolation
or the ability to inflict physical pain as a disciplinary measure.

No area was viewed. This information was also confirmed through staff and participant
interviews.

Buildings are equipped with ?re extinguishers, emergency exits plans and smoke

detectors that are placed conspicuously.

Fire extinguishers and smoke detectors were present in the main building and in the

participant sleeping guarters. An emergency exit plan was not present in the sleeping
guarters.

Any noted deficiencies in most recent Deputy State Fire Marshalls report have been

addressed.

Sean Thorne, WCA Director, was not sure when the last inspection by the State Fire
Marshall was completed. No known de?ciencies were noted in the 2016 PAARP

Inspection Report.

Program facilities are free from any major notable safety hazards or defects.

No safety hazards or defects were noted during the inspection.

If program is required to have periodic water quality testing and septic maintenance,
verify these inspections are current.

Water is tested and portable toilets are pumped 

Facility contains an adequately supplied first aid kit which is maintained and in good

working order.

First aid kit viewed in staff office.

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August 15, 2017
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Area medications are stored in a controlled area with limited access.

Medications are stored in staff of?ce. Participants are not allowed access to this room.

Food preparation and serving areas are adequate to ensure nutritional needs of
participants are met.

All areas appeared adequate.

Food preparation areas are operated in a clean and safe manner with all equipment,

storage and sewing tools in good working order.

All areas appeared to be in compliance.

Vehicles used to transport participants and staff has emergency information contained

in the vehicle. (Name, address, telephone of program and emergency phone numbers)

Emergency information is taken with them in the vehicle during transport.

Veri?ed if any newly constructed buildings or remodeling has been done within the last
18-24 months. If so, determine if building, plumbing and electrical permits were
received and proper inspections done upon completion of project.

No new construction has occurred.

Administrator Interview:

1.


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Comments:

Administrator explained policy for contraband check, including the circumstances in
which searches will be conducted and the training of staff conducting search.

Mr. Thorne explained the process.

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August 15, 2017

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Reviewed with Administrator at least two personnel files of employees to verify
background checks are on file and fingerprint checks have been performed.

Personnel files contained copies of fingerprints and background searches.

Reviewed with Administrator at least two program participant?s files to verify they are
kept within accordance of programs policy and federal and state laws for privacy.

Program participant files are stored in a ?le cabinet located in the staff office, which is

locked at the end of each day. Participants are not allowed access to the office.

Reviewed with Administrator at least two program participant?s files to verify that each

has an individual treatment plan in place. (at least one different from above two)

Program participant files appeared to be in compliance.

Review medication dispensation log to verify that kept up to date including information
on missed or refused dosages and medication changes.

Medication log reviewed and appeared to be in compliance.

Verify with Administrator that copies of all professional staff certifications are

maintained on the premise.

Staff certifications were viewed.

Staff Interviews - Combined answers of two staff members:

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Comments:

Staff explained definition of inappropriate and appropriate behaviors of program
participants.

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August 15, 2017

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Staff explained acceptable and unacceptable responses to inappropriate behaviors as
well as acceptable consequences to inappropriate behaviors.

The program utilizes a level system. Participants can earn up to 300 points per day and
are assigned a level based on the number of points accumulated weekly. As the

participant moves up levels, they are allowed more privileges and personal items.

Staff verified training in these areas has occurred and does reoccur at least annually.

Staff described yearly trainings.

Staff verified the purpose of physical labor (not for the sole purpose of punishment).

Staff explained physical labor is part of the program, but not for the sole purpose of
punishment.

Staff verified necessary food, clothing, bedding, rest, toilet use or bathing facilities are
not denied to participants as a form of punishment.

Staff stated alternate meals are served as a form of disciplineI which consist of oatmealI
powdered milk, and an apple. The alternate meals are served for a maximum of three

days. Staff also stated certain articles of clothing are removed as a deterrent. For
example, a participant?s pants were taken away when he tried to run away. Staff also
stated if a participant is placed in separation for bad behavior, he has to shower outside
using a hose and a tarp for privacy.

Staff verified that verbal abuse, ridicule, humiliation, profanity, threats or other forms of
degradation are not directed at participants or their families.

Staff indicated this does not occur.

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August 15, 2017

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Staff verified denial of visits or communication with parents/guardians does not occur
for the sole purpose of punishment (program guidelines, activities, plans or court orders
may require short periods where communication cannot occur).

Staff stated the freguency of communication with is dependent on

the participant?s level.

Veri?ed locked confinements or placing participants in a locked room for non-
therapeutic purposes are not used.

Not used.

Veri?ed the administration of medication for disciplinary purposes, the convenience of

staff or as a substitute for treatment services is not done.

Staff verified medication is only administered as prescribed.

Staff verified all punishment given to a participant is done with at least two staff
members present.

Veri?ed physical or mental suffering including pain to force compliance does not occur.
Does not occur.

The use of passive restraint is explained and falls within the program rules (only used in
a situation when an imminent threat to the participant, staff or others and only by

trained staff- CPI and MANDT).

Staff veri?ed they are trained in CPI.

Staff explained use of short term time out for behavior modification methods employed

at the facility.

Short term time outs are utilized.

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Staff explained procedures for handling emergency situations such as suicide
threat/attempt, assault or runaway.

Staff explained procedures for handling emergency situations.

Participant Interviews Combined answers of four participants

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Participants explained how staff deals with inappropriate and appropriate behaviors of
program participants.

Participants described the use of points and the level svstem.

Participants acknowledge having access to routine and emergent medical services as

needed, including mental health services.

Participants confirmed they have unrestricted access to these services.

Participants received handbook outlining expectations and acceptable standards of the

program.

Participants verified receiving a handbook.

Participants verified the purpose of physical labor (not for the sole purpose of

punishment).

Participants described physical labor. but not for the sole purpose of punishment.

Participants verified necessary food, clothing, bedding, rest, toilet use or bathing
facilities are not denied to participants as a form of punishment.

Participants stated alternate meals are served as a form of disciplineI which consist of

oatmeal, powdered milk, and an apple. Participant stated his pants were taken away
when he tried to run away. Participant stated there is another participant who has to
shower outside with a hose.

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Participants verified that verbal abuse, ridicule, humiliation, profanity, threats or other
forms of degradation are not directed at participants or their families.

Participants verified denial of visits or communication with parents/guardians does not
occur for the sole purpose of punishment (program guidelines, activities, plans or court
orders may require short periods where communication cannot occur).

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Partici ants stated all communication with arents uardians is monitored staff an
the freguency of phone calls is determined by the level system.

Locked con?nements or placing participants in a locked room for non-therapeutic
purposes are not used.

No area was viewed. This information was also confirmed by participant interviews.

The administration of medication for disciplinary purposes, the convenience of staff or

as a substitute for treatment services in not done.

Does not occur.

Participants verified all punishment given to a participant is done with at least two staff
members present. Determine if corporal punishment is used.

Corporal punishment is not used.

Physical or mental suffering including pain to force compliance does not occur.

Does not occur.

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August 15, 2017
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The use of passive restraint is explained and falls within the program rules (only used in
a situation when an imminent threat to the participant, staff or others and only by
trained staff? CPI and MANDT).

Comments:

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I [3 Participant explained use of short term time out for behavior modification methods
employed at the facility.

Comments: Participants described the use of short term time outs and referred to it as ?hold a tree?
because they have to keep one hand on a tree during the time out.

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