Corvallis Farm Home falsified records, hiding safety failures

From the Corvallis Gazette Times, November 22, 2016

Employees at a residential psychiatric treatment facility for children in Corvallis routinely failed to perform mandatory welfare checks and falsified records to hide that fact, according to Oregon licensing records.

The issues at the Children’s Farm Home came to light in August, when the state began investigating the suicide of a teenage boy. Staffers were supposed to check on him every 15 minutes, and documentation indicated he slept through the night on Aug. 15, according to state licensing records obtained by The Oregonian/OregonLive through a public records request.

Corvallis Farm Home, 2015

Corvallis Farm Home, 2015

In reality, the teen — who’d told staff earlier in the evening that he was suicidal and had been bleeding from self-inflicted arm wounds — made what state regulators described as “a serious suicide attempt” after staff left him alone for 40 minutes to take a shower that night.

Paramedics resuscitated the boy, but he “never regained brain function” and his parents decided to end life support, according to the state. The suicide was first reported by the Corvallis Gazette-Times in August. According to the newspaper, the boy was 15 years old when he died.

Other patients told regulators they also had gone without scheduled check-ins by the center’s employees.

The Oregon Department of Human Services, which licenses the Children’s Farm Home and other programs that care for children, has since started the process to revoke the home’s license. But the company that operates the home, Trillium Family Services, is fighting to keep the program open.

The state’s handling of the case invites comparisons to mixed enforcement signals the state sent Eastern Oregon Academy near Burns. Last week, The Oregonian/OregonLive reported that state investigators initially substantiated abuse and neglect allegations at the facility, only to be overruled by a top human services official.

Even as the state investigated the Children’s Farm Home, officials eased back on conditions they’d imposed on the program after the boy’s death. The apparent contradiction could be yet another sign that the state is held back from cracking down on programs with marred safety records because there aren’t other options for treating those patients. That conflict has been amplified by a newly passed law, which tightened requirements for the state to take action when young people are abused or neglected.

The Department of Human Services did not respond to several questions by deadline and referred other questions about the Children’s Farm Home to a spokesperson at the Oregon Health Authority, which certifies and oversees the treatment portion of the program. That agency did not respond by Monday evening.

The state initially slapped new conditions on the Children’s Farm Home license starting Aug. 19, including suspending admissions for several programs. The amended license also prohibited Children’s Farm Home staff who were the target of pending investigations or substantiated abuse or neglect complaints from working with youth.

Regulators soon softened those restrictions. On Aug. 25, the human services agency amended the license to allow those employees to work with youth if they’d been cleared by the agency’s “background check unit.” And on Sept. 14, the state allowed the Children’s Farm Home to resume admissions to all of its programs.

Kim Scott, president and CEO of Trillium Family Services, wrote in an email that, “We are in a formal appeal process regarding these matters and decline to comment at this time.”

The conditions that the state imposed on the Children’s Farm Home did not apply to Trillium’s other youth program in Oregon, The Parry Center for Children in Portland.

The problems at Children’s Farm Home are not new.
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Oregon human services and health officials “implemented a strict action plan requiring overnight checks in 2011, when a resident committed suicide” at the facility, human services licensing manager Harry Gilmore wrote in an Aug. 19 notice imposing new conditions. “Trillium is not compliant with the action plan.”

Licensing records detailed other failures at the Children’s Farm Home, including the failure to report “critical incidents” to human services employees such as “a resident’s multiple admissions to the Emergency Room for treatment of self-inflicted wounds.”

On the night of the boy’s suicide attempt in August, a staffer described as a “skills trainer” was monitoring him and noticed he’d made “superficial cuts” and had blood on his arms, according to the state’s notice of intent to revoke the program’s license.

The staffer later reported during a state investigation that “she did not like reading the residents’ background, treatment plans, or Advanced Behavior Directives when they entered the program, which include important information about mental health diagnoses and recommended interventions.” She hadn’t read these materials for the boy, who had spoken of suicide before.

When the employee gave the boy a towel to clean his arms, he was crying and told her, “I want to die,” according to the notice. Instead of contacting a supervisor or mental health worker about the statement — which could have resulted in the boy receiving additional supervision — the skills trainer allowed him to take a shower. She reported needing a break and left an “inexperienced, relatively untrained” staffer in charge without sharing the boy’s suicidal thoughts, according to the state.

When staffers gained access to the bathroom approximately 40 minutes later, they found the boy had hanged himself with a piece of clothing and was unresponsive.

State licensing officials ultimately concluded, “The resident’s death was a result of neglect on the part of (the Children’s Farm Home) employees …”