Section 801.350  Reports and Correspondence

The following reports or documents shall be forwarded to the Department as specified:

a)         Quarterly Reports

The Chief Administrative Officer shall submit a written quarterly report to the Licensing Administrator that includes, but is not limited to, copies of the following information for the reporting period:

1)         A synopsis of any internal audits conducted during the quarter, indicating any non-compliance issues.

2)         A summary of staff training conducted during the quarter.

3)         Any significant programmatic concerns.

4)         A report of personnel transactions, including positions vacated and filled during the quarter, and the total staff headcount.

5)         Any significant changes to the projected budget.

6)         Reports of all fire drills conducted during the quarter.

7)         Reports of all inspections conducted by outside agencies, including, but not limited to, the State Fire Marshal, the Department of Public Health, and independent fiscal auditors.

8)         Weekly inspection forms that report a deficiency in any area and a summary of the steps taken to resolve the problem.

b)         Fiscal Reports

The Chief Administrative Officer shall submit copies of the following information for the reporting period to the Licensing Administrator:

1)         The annual approved budget and any approved revision;

2)         All fiscal reports made to the governing body; and

3)         Financial audits.

c)         Daily Population Report

1)         A daily population report shall be provided to the Licensing Administrator by 10:00 a.m. that includes information for the preceding 24-hour period which ended at midnight.

2)         The report shall include:

A)        The total number of youth:

i)          Assigned to secure care at the facility.

ii)         Physically present at the facility.

iii)         Absent from the facility, by classification of absence, due to reasons, such as medical, court, authorized absence, or unauthorized absence.  The names and identification numbers of each youth shall be included for each classification.

iv)        Who have entered the facility on a secure care placement, including the names and identification numbers of each youth.

v)         Who have been removed from secure care placement at the facility, including the names and identification numbers of each youth.

B)        A recapitulation at the end of the report to account for all youth assigned to the facility, whether present or absent.

d)         Annual Survey of Youth Needs

An annual survey of youth needs shall be provided in accordance with Section 801.810(b) of this Subpart.

e)         Unusual Incident Reports

1)         Unusual incidents or situations that occur on the grounds of a secure care facility or that occur within the community involving an on-duty employee or an individual under secure care supervision shall be reported to the appropriate officials and completely documented by the witnessing employee or the employee who received notification of same prior to the end of his or her shift.  The unusual incident report shall be maintained in a separate confidential administrative file and shall include the following:

A)        The facility name.

B)        The date and time of the incident.

C)        The names and, if applicable, the identification numbers of the staff and youth involved in the incident.

D)        The names and, if applicable, the identification numbers of witnesses to the incident.

E)         A complete narrative of the facts and circumstances of the incident.

F)         The signature of the reporting staff member and the date and time the report was written.

G)        The signature of the reviewing supervisory staff member and the date and time the report was received.

H)        An assessment by the Chief Administrative Officer or designee and his or her signature and the date reviewed.

2)         The Chief Administrative Officer or designee shall report immediately, by telephone, to the Licensing Administrator any of the following types of incidents or situations that occur on the grounds of the facility or which involve an on-duty employee or youth on an assignment away from the facility:

A)        A youth's physical assault on another youth or any person where serious injury results requiring medical treatment.

B)        An arrest of staff or youth.

C)        Use of force by an employee on youth including use of physical force to restrain.

D)        A youth's suicide attempt.

E)         Any serious illness or injury to youth which requires medical attention.

F)         Any escape, runaway, attempted escape or runaway, or unauthorized absence.

G)        Death of a youth.

H)        Major property loss or damage.

I)          Any serious fire or arson attempt.

J)         Any youth or employee action which the facility may refer for prosecution of criminal charges.

K)        Use of restraints for purposes other than escort or transport security.

L)         Any body cavity or strip search of youth.

M)       Any youth's diagnosed pregnancy.

N)        Other incidents or situations which in the opinion of the Chief Administrative Officer should be reported.

O)        Any other incidents or situations which may result in legal action or require an administrative response by the Department.

3)         The Chief Administrative Officer of the secure care facility, after immediately informing the Licensing Administrator by telephone of the incident, shall ensure:

A)        An initial incident report is completed and transmitted to the Licensing Administrator by the next working day or within 72 hours after the incident if the incident occurs on the weekend.  The initial report may be designated as the final report.

B)        A progress report or final follow-up report is transmitted to the Licensing Administrator within 15 days after the incident, if applicable.  A progress report shall be transmitted to the Licensing Administrator as additional information is available, but not less frequently than every 90 days after the date of the last report until submission of the final report.

f)          Legal Documents

The Licensing Administrator shall promptly be sent copies of all documents and correspondence received related to any youth's pending legal matters including, but not limited to, custody disputes, actions to terminate parental rights, or other actions affecting the youth's placement, treatment, or secure care status.  The facility shall confer with the Licensing Administrator related to all issues or concerns raised by these documents.  Producing documents and reports as ordered by the courts or requested by attorneys or other persons shall be the responsibility of the facility unless otherwise advised.