STATE OF MICHIGAN

DEPARTMENT OF HEALTH AND HUMAN SERVICES

GRETCHEN WHITMER ROBERT GORDON
GOVERNOR
LANSING DIRECTOR

March 24, 2021

Judith Fischer-Wollack, Licensee Designee

Wolverine Human Services
15100 Mack Avenue
Grosse Pte. Park,, MI 48231

License #: CI730201515
Wolverine Secure Treatment Center

Dear Ms. Fischer-Wollack:

Enclosed is a copy of a NOTICE OF INTENT TO REVOKE the license of Wolverine Secure

Treatment Center. Pursuant to MCL 722.117a(3). this NOTICE OF INTENT provides written
notice of the grounds for the revocation of the license.

An informal compliance conference has been scheduled regarding this matter. The date, time
and location of this conference are specified in the enclosed NOTICE OF COMPLIANCE
CONFERENCE. A licensee is also entitled to waive the compliance conference and proceed
directly to a contested case hearing before an administrative law judge (ALJ).

Pursuant to MCL 722.121(2), you have 30 days from the date of receipt to appeal this Notice.
If the Department does not receive your written appeal within 30 days of your receipt of this
Notice, you will have WAIVED YOUR RIGHT to an administrative law hearing and the
revocation of the license will be final.

Sincerely,

Rachel Willis, Director

Division of Child Welfare Licensing
Department of Health and Human Services

Enclosures

cc: Linda Tansil, Area Manager

Paul Whitney, Chief Administrator

P.O. BOX 30650 • LANSING, MICHIGAN 48909-8150

www.michigan.gov • (517) 284-9727
 STATE OF MICHIGAN
DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF CHILD WELFARE LICENSING

In the matter of License #: CI730201515

Wolverine Secure
Treatment Center
Wolverine Secure Treatment Center

______________________________________/

NOTICE OF INTENT TO
REVOKE LICENSE

The Michigan Department of Health and Human Services, by Rachel Willis, Director,

Division of Child Welfare Licensing (“DCWL”), provides notice of the intent to revoke the

license of Licensee, Wolverine Human Services. This revocation is pursuant to the authority

of the Child Care Organizations Act, 1973 PA 116, as amended, MCL 722.111 et seq.

DCWL provides the following as the proposed grounds for revocation of the license:

LICENSE AND PROGRAM BACKGROUND

On or about September 1, 1997, Licensee was issued a license to operate a child

caring institution at 2424 N Outer Drive, Saginaw, MI 48601. Wolverine Secure Treatment

Center (“the facility”) is a 100-bed child caring institution licensed to provide juvenile justice

services to youth in the State of Michigan. Judith Fischer-Wollack is the current Licensee

Designee of Wolverine Secure Treatment Center and Paul Whitney is the Chief

Administrator of the facility.

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 NOTICE OF VIOLATIONS AND BASIS FOR REVOCATION

Special Investigation Report # 2021C0325012

On February 8, 2021, DCWL modified the license of Wolverine Secure Treatment

Center to a second provisional status. The modification of the license was due to willful

and substantial licensing rule violations cited in several special investigation reports

concluded between October and December of 2021. In March 2021, DCWL concluded

three additional special investigations that led to further citation of willful and substantial

licensing rule violations1. Licensee failed to maintain compliance with child caring

institution licensing rules on multiple occasions. DCWL therefore provides the following

allegations as a basis to revoke the license of Wolverine Secure Treatment Center:

1. On January 17, 2021, Supervisor 1 and Supervisor 2 initiated two improper and

unsafe physical restraints of Youth A at the facility. The following occurred

during these restraints:

a. At 12:55 p.m., Youth A attempted to exit the gym area through a door.

Supervisor 2 approached Youth A and placed his hands on her. Youth A

swung her arm at Supervisor 2. At that time, Supervisor 1 ran up from

behind Youth A and jumped up off the ground, landing on Youth A’s

back, while wrapping his arm around Youth’s A shoulder and neck area.

This is not an approved Therapeutic Crisis Intervention (TCI) technique.

Youth A then fell to the floor.

b. While on the floor, Youth A’s head was positioned in between Supervisor

2’s knees momentarily, and then Supervisor 2 moved to the left side of

1 SIR #2021C0325012, SIR #2021C0106015 and SIR #2021C0207008

3
 Youth A while Youth a was laying in a supine position on the floor. This

is not an approved TCI technique.

c. Surveillance video from the restraint shows Supervisor 1 moving his

elbow quickly down towards Youth A’s face. Supervisor 1 then

proceeded to place his body weight down on Youth A. Youth A later

reported to Licensing Consultant Venus Decker that she was punched in

the face during the restraint by Supervisor 1.

d. The floor restraint on Youth A continued for approximately four minutes

until Youth A was released. Supervisor 1 and Supervisor 2 released

Youth A from the first restraint at 12:58 p.m.

e. At 1:00 p.m., Supervisor 1, Supervisor 2 and Supervisor 3 initiated a

second improper and unsafe restraint of Youth A at the facility.

f. After being released from the first restraint, Youth A began putting on her

shoes. Youth A was putting on her tennis shoes when Supervisor 1

attempted to grab Youth A’s shoe away from her. Youth A then pushed

Supervisor 1 away.

g. Supervisor 1 and Supervisor 2 initiated a physical restraint of Youth A.

The restraint violated TCI protocol, as Youth A was in close proximity to

a wall when the restraint was initiated. Supervisor 1 wrapped his arms

around Youth A’s waist, while Supervisor 2 placed his arms around

Youth A’s neck. This is not an approved TCI technique.

4
 h. Supervisor 1 proceeded to loosen his hold on Youth A, and Youth A fell

to the floor. Supervisor 2 placed his left hand on Youth A’s face while

she was on the floor. Supervisor 3 pinned Youth A’s legs to the floor.

i. Supervisor 2 then crawled over Youth A’s face, pressing his knee and

foot into Youth A’s face. This is not an approved TCI technique.

j. Supervisor 1 then used his knees and body weight to pin Youth A’s

hands to the floor. This is not an approved TCI technique.

k. This restraint was not performed in a manner proportionate to the

severity of the child’s behavior.

l. Following the physical restraints on January 17, 2021, Youth A

presented with a black eye with broken blood vessels in her eye.

Licensee failed to obtain immediate medical attention for Youth A.

2. On January 17, 2021, at approximately 2:45 p.m., Supervisor 1 and Supervisor

2 initiated an improper and unsafe physical restraint of Youth B at the facility.

The following occurred during this restraint:

a. Staff placed Youth B in her bedroom. A short time later, Supervisor 1,

Supervisor 2 and Staff 6 entered Youth B’s room, as the youth had small

metal objects and a CD on her.

b. Staff 6 requested to perform a body check on Youth B, who was sitting

on her bed. Youth B resisted, and then Supervisor 1 and Supervisor 2

began restraining Youth B by holding her arms.

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 c. During the restraint, Youth B was half-on and half-off the bed and

Sometime during the restraint, Youth B struck her head and Supervisor 2

elbowed Youth B.

d. Licensee’s incident report dated January 17, 2021, indicated that staff

utilized the TCI “control technique” with Youth B. This technique requires

the assistance of three staff when restraining a youth. Only Supervisor 1

and Supervisor 2 initiated this restraint of Youth B.

e. Following the physical restraint of Youth B on January 17, 2021, Youth B

complained of head pain. Youth B also had an area of swelling on her

forehead. Licensee failed to obtain immediate medical attention for

Youth B. On January 19, 2021,

3. Following the physical restraints of Youth A on January 17, 2021, Youth A told

Staff 1, Staff 2 and Staff 3 that Supervisor 1 hit her in the eye. Ms. Decker

interviewed Staff 1, Staff 2, and Staff 3 in February 2021. All three staff

reported that Youth A had some type of injury to her eye. None of the staff

contacted Children’s Protective Services’ Centralized Intake to report

suspected abuse. As a result, Licensee’s staff failed to immediately report the

suspected abuse to the Department.

4. Following the physical restraints of Youth A and Youth B, Licensee’s staff failed

to properly debrief after each incident. Licensee also failed to assure that the

incidents were reviewed with Youth A and Youth B after they had calmed.

6
5. On January 17, 2021, at 2:45 p.m. Youth B was placed in seclusion in her

bedroom after being restrained by Supervisor 1 and Supervisor 2. Licensee

failed to have the required records regarding this seclusion, as demonstrated

by the following:

a. The facility’s chief administrator did not provide written authorization to

place Youth B into seclusion.

b. Staff failed to record visual supervision checks of Youth B while she was

in seclusion.

c. Staff and youth debriefing forms were not completed by the Licensee’s

staff.

6. Supervisor 1, Supervisor 2 and Supervisor 3 lack suitability to assure the

welfare of children, as evidenced by the following:

a. On January 28, 2021, Licensing Consultant Venus Decker reviewed

Supervisor 1’s personnel file. Supervisor 1 had 18 employee counseling

memorandums in his personnel file. Since August 2017, Licensee issued

formal notices of discipline to Supervisor 1 for reasons such as not

presenting to work and placing youth in unsafe situations.

b. On February 2, 2021, Ms. Decker interviewed Supervisor 3 regarding the

physical restraint of Youth A that she assisted with on January 17, 2021.

Supervisor 3 stated that she had her eyes closed throughout the

restraint. When questioned about her job duties during a restraint,

Supervisor 3 acknowledged that it was her duty to be aware of the youth

and actions of other staff participating in the restraint. Supervisor 3 then

7
 stated that she did not have her eyes closed throughout the entire

restraint and that she did have some awareness of what was happening.

c. On February 2, 2021, Ms. Decker interviewed Supervisor 1 regarding the

physical restraints of Youth A that occurred on January 17, 2021.

Supervisor 1 indicated that when he jumped on Youth A’s back, he was

completing a technique called “the Wolverine assist.” Supervisor 1

explained that “the Wolverine assist” is when a staff jumps on a youth

from behind to initiate a physical restraint of a youth.

d. On February 2, 2021, Supervisor 1 admitted to Ms. Decker that he was

not aware of Youth A’s specific identified treatment modalities or past

traumas that may impact how Youth A should be handled. Supervisor 1

reported he did not know what was in Youth A’s Individual Crisis

Management Plan (ICMP) or her Speed Map, which are tools identified

by the Licensee to help Youth A with her challenging behavior.

e. On February 2, 2021, Ms. Decker questioned Supervisor 1 and

Supervisor 3 regarding the second physical restraint of Youth A on

January 17, 2021. Both Supervisor 1 and Supervisor 3 reported that they

restrained Youth A the second time because she was putting on her

tennis shoes. Supervisor 1 and Supervisor 3 indicated that they were

permitted to grab Youth A’s tennis shoes from her and restrain her

because if she was successfully able to put on her tennis shoes, she

would have a better grip on the floor to resist staff. This is not an

appropriate justification to restrain a youth under TCI protocol.

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 f. On February 9, 2021, Ms. Decker interviewed Trainer 1. Trainer 1 is the

Licensee’s certified TCI trainer. Trainer 1 reported he has not trained to

physically manage a child for putting shoes on their feet because they

may be getting ready to fight. Trainer 1 further stated that he has not

trained staff on “the Wolverine assist” restraint technique, as explained

by Supervisor 1.

g. Supervisor 2 did not cooperate with Ms. Decker’s investigation and

refused to be interviewed.

h.

7. Licensee failed to complete an accurate job performance evaluation regarding

Supervisor 1. Despite being formally counseled on 18 occasions between

August 2017 and February 2021, Licensee assessed Supervisor 1’s job

performance to be adequate. Supervisor 1’s history of counseling

memorandums was not addressed in any of his performance evaluations.

8. On February 2, 2021, Ms. Decker reviewed Licensee’s surveillance video

footage from the January 17, 2021, restraints of Youth A and Youth B. During

these incidents, Youth C and Youth D went into their bedrooms. Licensee’s

staff failed to complete eye-on checks at variable intervals not to exceed 15

minutes, as evidenced by the following:

9
 a. Youth D went into her bedroom and shut the door at 10:30 a.m. The next

visual check on Youth D did not occur until 10:52 a.m., when Youth D

was asked to be let out of her bedroom to use the bathroom.

b. Youth D returned to her bedroom at 10:57 a.m. Staff did not complete

another visual check on Youth D until 12:04 p.m.

c. Youth D came out of her room at 12:13 p.m. and returned to her room at

12:14 p.m. Staff did not conduct another eye-on check of Youth until

12:49 p.m.

d. Youth C went into her bedroom and shut the door at 10:53 a.m. Staff 1

did not perform a visual check of Youth C until 12:22 p.m.

Special Investigation Report #2021C0106015

9. On January 22, 2021, staff members , and

initiated an unsafe and improper physical restraint of Youth E 2

at the facility, as exhibited by the following:

a. Youth E got into a verbal dispute with staff, went into her bedroom and

crawled underneath her bed.

b. proceeded to grab Youth E by her legs while and

grabbed Youth E by her shirt and waistband and dragged

her out from underneath the bed.

2
Youth E is referred to as “Youth A” in SIR #2021C0106015

10
c. Youth E resisted and attempted to kick the staff away from her. The staff

then initiated a floor restraint with Youth E. At that time, Youth E bit

on the hand.

d. Youth E attempted to lift her head and grabbed Youth E’s

neck and pushed Youth E’s head down to the floor.

e. Youth E proceeded to spit at . cursed at Youth E.

Staff member then replaced in the restraint,

while left the room.

f. During the restraint, and pulled Youth E’s shirt

over Youth E’s head to keep her from spitting.

g. The physical restraint of Youth E was not proportionate to the severity of

Youth E’s behavior. Staff failed to utilize de-escalation techniques with

Youth E, and instead, dragged her out from underneath her bed and

restrained her for being noncompliant.

h. On January 26, 2021, Youth E was interviewed by . Youth E

presented with the following injuries:

i. A bruise on the left side of her forehead near her hairline;

ii. Bruises on both of her shoulders;

iii. An abrasion on the right side of her neck that looked like a scratch

or rug burn;

iv. A bruise on her right-side rib area; and

v. Bruises on her forearms.

11
10. Licensee’s program statement indicates that assessment and collaboration with

workers and family are used to identify each youth’s individual strengths and

challenges. Licensee states that it utilizes trauma-informed approach to each

youth’s treatment planning to ensure that the youth’s individualized needs are

met. On February 12, 2021, Licensing Consultant Mark Hunter interviewed

, Youth E’s therapist at the facility. denied having

much knowledge of the incident under investigation. stated he had

discussed the incident with Youth E’s family but was unaware of what Youth E

may have reported. denied receiving incident reports dealing with

youth behaviors and needs and stated that he did not keep any detailed notes

of counseling sessions. Youth E’s parents indicated that there was a lack of

communication from . conduct is inconsistent with

providing the services outlined in Licensee’s program statement.

did not facilitate family counseling over a two-month time span despite Youth

E’s mother attempting to contact on more than one occasion.

11. Licensee failed to immediately report the incident regarding Youth E to

Children’s Protective Services’ Centralized Intake. Following the incident, Youth

E alleged that punched her in the head during the restraint. Youth E

also had injuries as a result of this incident. became aware of

Youth E’s allegations on January 22, 2021, yet this information was not

reported to Centralized Intake until January 25, 2021.

12
 Special Investigation Report #2021C0207008

12. On January 27, 2021, staff member initiated an unsafe and

improper physical restraint of Youth F3 at the facility. wrapped

up Youth F in his arms and placed his right leg behind Youth F’s legs to take

her to the ground. This is not an approved TCI restraint technique.

13. On January 27, 2021, Licensee failed to record an accurate incident report

regarding the physical restraint of Youth F. Licensee’s staff falsely recorded

that the restraint was two minutes in duration when the restraint actually lasted

five and a half minutes.

14. On February 3, 2021, Licensing Consultant Kari Muntean reviewed surveillance

video footage of the physical restraint involving Youth F. Youth F was

restrained because she was punching out windows with her hand. During the

video, other youth were observed to clean up the broken glass and Youth F’s

blood off the floor, creating a safety hazard for youth in care.

LICENSING HISTORY AND PRIOR RULE VIOLATIONS

Since March 2019, DCWL has conducted 63 special investigations of the

Licensee’s facility, 23 of which established rule violations, including the following:

15. On May 6, 2019, Ms. Decker initiated a special investigation of the facility (SIR

#2019C0325040). Ms. Decker determined that a staff member was verbally

inappropriate and engaged in physical horseplay with residents, R 400.4109(1)(c).

3
Youth F is referred to as “Youth A” in SIR #2021C0207008

13
 Another staff member tackled a youth at the facility and did not perform a safe or

appropriate restraint, in violation of R 400.4159(2). On June 18, 2019, Licensee

submitted a CAP that addressed these rule violations.

16. On May 25, 2019, Ms. Decker initiated a special investigation of the facility (SIR

#2019C0325044). Ms. Decker determined that a staff member failed to use proper

TCI intervention strategies and physically elbowed a youth in the face area during

the restraint, in violation of R 400.4157(2)(b), R 400.4159(2), and R

400.4112(4)(a). On August 1, 2019, Licensee submitted a CAP that addressed

these rule violations.

17. On June 21, 2019, Ms. Decker initiated a special investigation of the facility (SIR

#2019C0325051). Ms. Decker determined that the facility did not refill a youth’s

medication in a timely manner; therefore, the youth missed four dosages of

medication, in violation of R 400.4142(1)(a). On August 16, 2019, Licensee

submitted a CAP that addressed this rule violation.

18. On July 1, 2019, Ms. Decker initiated a special investigation of the facility (SIR

#2019C0325050). Ms. Decker determined that a staff member fell asleep while on

third shift and demonstrated an inability to perform his job duties, in violation of R

400.4126 and R 400.4112(4)(a). On August 12, 2019, Licensee submitted a CAP

that addressed these rule violations.

19. On July 25, 2019, Ms. Decker initiated a special investigation of the facility (SIR

#2019C0325053). Ms. Decker determined that a staff member brought in a

marijuana vape pen and allowed youth to use it, in violation of R 400.4109(1)(c).

Staff also allowed youth to engage in sexual inappropriate behavior while under

14
 blankets and discussed her personal life with male staff members, in violation of R

400.4112(4)(a). On December 2, 2019, Licensee submitted a CAP that addressed

these rule violations.

20. On September 17, 2019, Ms. Decker initiated a special investigation of the facility

(SIR #2019C0325063). Ms. Decker determined that a staff member “arm-

checked” a youth to create distance between himself and the youth, causing the

youth to fall, in violation of R 400.4157(2)(b). On November 27, 2019, Licensee

submitted a CAP that addressed this rule violation.

21. On September 19, 2019, Ms. Decker initiated a special investigation of the facility

(SIR #2019C0325064). Ms. Decker determined that a staff member engaged in a

romantic relationship with a youth, in violation of R 400.4109(1)(c). The staff

member also threatened to extend the youth’s stay at the facility when she broke

off the relationship. She discussed her personal life with the youth and looked for

his support on personal matters, in violation of R 400.4112(4)(a). On January 6,

2020, Licensee submitted a CAP that addressed these rule violations.

22. On September 24, 2019, Ms. Decker initiated a special investigation of the facility

(SIR #2019C0325061). Ms. Decker determined that a staff member was yelling at

a youth and used profanity towards the youth, in violation of R 400.4157(2)(b). On

January 8, 2020, Licensee submitted a CAP that addressed this rule violation.

23. On October 1, 2019, Ms. Decker initiated a special investigation of the facility (SIR

#2020C0325009). Ms. Decker determined that a staff member punched a youth’s

right mid-section before a standing hold restraint, in violation of R 400.4158(2)(a).

While the youth was on the floor in a supine restraint, the staff member punched

15
 him in the face with a closed fist, resulting in a nosebleed, in violation of R

400.4159(1) and R 400.4112(1)(a). On December 20, 2019, Licensee submitted a

CAP that addressed these rule violations. Due to the quantity and severity of the

violations cited during Ms. Decker’s October 2019 special investigation, Ms.

Decker recommended the issuance of a first provisional license.

24. On October 15, 2019, Licensing Consultant Vivian Malleck initiated a special

investigation of the facility (SIR #2020C0217002). Ms. Malleck found that staff

completed variable interval, eye-on checks of a youth exceeded fifteen minutes

when she was outside the direct supervision of staff, in violation of R 400.4127(4).

The youth created a knotted and twisted makeshift rope from a bedsheet to tie

around her neck and commit suicide while alone in her bedroom. The youth had

prior suicidal gestures and the facility failed to complete a suicide screening

assessment, in violation of R 400.4109(1)(c). Due to the quantity and severity of

the violations cited during Ms. Malleck’s October 2019 special investigation, Ms.

Malleck recommended the issuance of a first provisional license.

25. On October 31, 2019, Ms. Decker initiated a special investigation of the facility

(SIR #2020C0325011). Ms. Decker determined that a staff member used her

body to push a youth into a wall and keep her subdued, in violation of R

400.4157(2)(b). On January 8, 2020, Licensee submitted a CAP that addressed

this rule violation.

26. On December 5, 2019, Ms. Decker initiated a special investigation of the facility

(SIR # 2020C0325018). Ms. Decker determined that an unauthorized visitor was

16
 able to visit with a youth at the facility, in violation of R 400.4109(1)(c). On

January 8, 2020, Licensee submitted a CAP that addressed this rule violation.

27. On December 6, 2019, Ms. Decker initiated a special investigation of the facility

(SIR #2020C0325015). Ms. Decker determined that a nurse at the facility missed

trazadone medication dosages for a youth, in violation of R 400.4142(1)(e). On

January 31, 2020, Licensee submitted a CAP that addressed this rule violation.

28. On December 12, 2019, Licensing Consultant Christopher Barr initiated a special

investigation of the facility (SIR #2020C0219008). Mr. Barr determined that

Licensee was using its contractual teachers to serve in the capacity of a direct

care worker. The facility’s personnel records of teachers did not contain a job

description which delineated their prescribed duties and functions, in violation of R

400.4111. A staff member left a teacher to supervise six to eight youth, whereas

the staff-to-youth ratio is one staff to five youth, in violation of R 400.4127. On

March 17, 2020, Licensee submitted a CAP that addressed these rule violations.

29. On April 20, 2020, Licensing Consultant Mark Hunter initiated a special

investigation of the facility (SIR # 2020C0106034). Mr. Hunter found that a staff

member did not follow the facility’s behavior management policy during the

restraint of Youth A by spitting on a youth, in violation of R 400.4157(1). On

September 2, 2020, Licensee submitted a CAP that addressed this rule violation.

30. On May 28, 2020, Mr. Hunter initiated a special investigation of the facility (SIR

#2020C0106042). Mr. Hunter found that a staff member fell asleep and failed to

supervise two youth. Staff member was in close proximity of the two youth, but he

failed to maintain line-of-sight supervision and awareness of both youth, in

17
 violation of R 400.4126 and R 400.4109(1)(c). The staff had a history of

convictions that required the facility to complete an evaluation for suitability for

employment in this facility, in violation of R 400.4113. On September 2, 2020,

Licensee submitted a CAP that addressed this rule violation.

31. On June 2, 2020, Ms. Decker initiated a special investigation of the facility (SIR #

2020C0325044). Ms. Decker found that a staff member made derogatory and

inappropriate remarks and statements to a youth, in violation of R 400.4158(2).

These remarks were abusive and humiliating in nature. Ms. Decker also found

youth were stealing food from the younger youth and staff did not intervene, in

violation of R 400.4109(1)(c). On August 31, 2020, Licensee submitted a CAP that

addressed this rule violation.

32. On June 26, 2020, Mr. Hunter initiated a special investigation of the facility. (SIR #

2020C0106048). Mr. Hunter found that a staff member violated the medication

policy of the facility when she became distracted, which allowed a youth to take

some medications from the dispensing cart, in violation of R 400.4142(1). On

August 31, 2020, Licensee submitted a CAP that addressed this rule violation.

33. On August 31, 2020, Licensing Consultant Barbara Cote initiated a special

investigation of the facility (SIR # 2020C0116009). Ms. Cote found that staff

member was working alone in two units. Licensee violated its contracted ratio on

more than one occasion, in violation of R 400.4127. On October 14, 2020,

Licensee submitted a CAP that addressed this rule violation.

34. On September 18, 2020, Ms. Cote initiated a special investigation of the facility

(SIR #2020C0116011). Ms. Cote determined that a staff member used

18
 mechanical restraints on a youth and handcuffed him to his bed, in violation of

Emergency Rule 1 and Emergency Rule 2.

35. On October 1, 2020, Mr. Hunter initiated a special investigation of the facility (SIR

#2021C0106002). Mr. Hunter concluded that Licensee failed to maintain its

contracted ratio. Licensee also failed to comply with staff-to-youth ratio under the

Prison Rape Elimination Act.

36. On November 5, 2020, Ms. Cote initiated a special investigation of the facility (SIR

#2021C0116006). Ms. Cote found the following rule violations:

a. A staff member left the unit without getting coverage, leaving a youth

without her required one-to-one staffing, in violation of R 400.4126. The

youth attempted suicide while unsupervised.

b. An incident report was not completed accurately to describe the incident

and context within which it occurred, in violation of R 400.4109(1)(c).

c. The staff member lacked the ability to perform the duties of the position, in

violation of R 400.4112(4).

On or about February 8, 2021, Licensee submitted a CAP that addressed this rule

violation.

37. On November 15, 2020, Ms. Decker initiated a special investigation of the facility

(SIR #2021C0325004). Ms. Decker found the following rule violations:

a. Only one staff member was on duty with nine youth, in violation of R

400.4126.

b. A youth was not properly supervised and swallowed multiple batteries as a

result, in violation of R 400.4126.

19
 c. A youth was improperly placed into seclusion when his behavior did not

warrant the discipline, in violation of R 400.4161(1).

d. Licensee failed to complete documentation regarding the seclusion of the

youth, in violation of R 400.4162.

e. A group of youth were no longer permitted to watch television or play video

games due to the behavior of a single youth, in violation of R 400.4158(2).

f. Licensee failed to adhere to their Critical Incident Response and Reporting

Residential Programs policy, in violation of R 400.4109(1)(c).

g. Treatment plans were not being followed for youth.

On or about February 8, 2021, Licensee submitted a CAP that addressed this rule

violation.

38. Due to the quantity and severity of the violations cited in the special investigation

reports referenced in paragraphs 29 to 35 of this Notice, DCWL issued Licensee a

first provisional license on January 13, 2021.

39. Due to the quantity and severity of the violations cited in the special investigation

reports referenced in paragraphs 36 and 37 of this Notice, DCWL issued Licensee

a second provisional license on February 8, 2021. The license remains at a

second provisional status.

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 CONCLUSION AND RULE VIOLATIONS

COUNT I

The conduct of Licensee, as set forth in paragraphs 1 through 14 above, evidences a

willful and substantial violation of:

R 400.4109 Program statement.

(1) An institution shall have and follow a current written program
statement which specifically addresses all of the following:

(c) Policies and procedures pertaining to admission, care,

safety, and supervision, methods for addressing
residents’ needs, implementation of treatment plans, and
discharge of residents.

COUNT II

The conduct of Licensee, as set forth in paragraphs 1 through 14 above, evidences a

willful and substantial violation of:

R 400.4112 Staff qualifications.

(4) A person with ongoing duties shall have both of the
following:

(a) Ability to perform duties of the position assigned.

(b) Experience to perform the duties of the position

assigned.

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 COUNT III

The conduct of Licensee, as set forth in paragraph 3 above, evidences a willful and

substantial violation of:

Emergency Rule 1

(2) Resident restraint must be performed in a manner that is safe,

appropriate, and proportionate to the severity of the minor child's
behavior, chronological and developmental age, size, gender,
physical condition, medical condition, psychiatric condition, and
personal history, including any history of trauma, and done in a
manner consistent with the resident's treatment plan.

COUNT IV

The conduct of Licensee, as set forth in paragraphs 1 through 6, 9 and 12 above,

evidences a willful and substantial violation of:

Emergency Rule 2

…The written policy must include all of the following:

(a) Procedures for debriefing of the restraint among the staff involved and
supervisors immediately following the end of the restraint that examines
preventive strategies that could have been used to avoid the restraint

(b) Procedures for debrief with the youth restrained that includes the
examination from the youth’s perspective of preventive strategies that
could have been used to help support the youth to avoid behavior or
that would have helped the youth deescalate from behaviors that placed
the youth or others at risk.

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 COUNT V

The conduct of Licensee, as set forth in paragraphs 1 through 6, 9 and 12 above,

evidences willful and substantial a violation of:

R 400.4157 Behavior management.

(1) An institution shall establish and follow written policies and
procedures that describe the institution’s behavior management
system. The policies and procedures shall be reviewed annually
and updated as needed. These shall be available to all
residents, their families, and referring agencies.

COUNT VI

The conduct of Licensee, as set forth in paragraphs 1 through 6, 9 and 12 above,

evidences a willful and substantial violation of:

R 400.4158 Discipline.
(2) An institution shall prohibit all cruel and severe discipline,
including any of the following:

(a) Any type of corporal punishment inflicted in any

manner.
(b) Disciplining a group for the misbehavior of individual
group members.
(c) Verbal abuse, ridicule, or humiliation.
(d) Denial of any essential program services, including
adoption planning.
(e) Withholding of food or creating special menus for
behavior management purposes.
(f) Denial of visits or communications with family.
(g) Denial of opportunity for at least 8 hours of sleep in a
24-hour period.
(h) Denial of shelter, clothing, or essential personal
needs.

23
 COUNT VII

The conduct of Licensee, as set forth in paragraphs 3 and 11 above, evidences a

willful and substantial violation of:

R 400.4131 Compliance with child protection law; development of plan

required.
The licensee shall develop and implement a written plan to
assure compliance with the child protection law, 1975 PA 238,
MCL 722.621 to 722.638.

COUNT VIII

The conduct of Licensee, as set forth in paragraphs 1 and 2 above, evidences a

willful and substantial violation of:

R 400.4142 Health services; policies and procedures.

(1) An institution shall establish and follow written health service

policies and procedures addressing all of the following:

(a) Routine and emergency medical, and dental, and

behavioral health care.

24
 COUNT IX

The conduct of Licensee, as set forth in paragraph 8 above, evidences a willful and

substantial violation of:

R 400.4127 Staff-to-resident ratio.

(4) When residents are asleep or otherwise outside of the direct
supervision of staff, staff shall perform variable interval, eye-on
checks of residents. The time between the variable interval
checks shall not exceed fifteen minutes.

COUNT X

The conduct of Licensee, as set forth in paragraph 5 above, evidences a willful and

substantial violation of:

R 400.4161 Seclusion rooms; policies and procedures.

An institution approved to use a seclusion room shall establish
and follow written policies and procedures specifying its use.
The policy shall include, at a minimum, all of the following
provisions:

(a) Seclusion shall be performed in a manner that is safe,

appropriate, and proportionate to the severity of the minor
child’s behavior, chronological and developmental age,
size, gender, physical condition, medical condition,
psychiatric condition, and personal history, including any
history of trauma.

(b) The room may only be used if a resident is in danger

of jeopardizing the safety and security of himself, herself,
or others.

(c) The room shall be used only for the time needed to
change the behavior compelling its use.

(e) Staff shall observe the resident at intervals of 15

minutes or less and shall record the observation in a

25
 seclusion room log. Video surveillance shall not be the
only means of observation.

(f) The log shall include all of the following information:

(i) Name of resident.
(ii) Time of each placement.
(iii) Name of staff person responsible for
placement.
(iv) Description of specific behavior requiring use
or continued use of the room and interactive
strategy for removal.
(v) Medical needs addressed during seclusion,
including medication administration.
(vi) Time of each removal from the room.

NOTICE IS GIVEN that, Licensee is offered the opportunity to show compliance

with all lawful requirements for retention of the license. If Licensee appeals the Notice

of Intent and compliance is not shown, formal proceedings will be commenced pursuant

to the Child Care Organizations Act, 1973 PA 116, and the Administrative Procedures

Act, 1969 PA 306, as amended; MCL 24.201 et seq. Should formal proceedings

commence, you have the right to attorney representation at your own expense.

LICENSEE IS NOTIFIED that pursuant to MCL 722.121(2) of the Child Care

Organizations Act, Licensee has 30 days from the date of receipt of this Notice of Intent

to file a written appeal of this proposed action. The appeal shall be addressed to Kelly

Maltby, Division of Child Welfare Licensing. Your written appeal must include your name

and license number, and must be submitted using one of the following methods:

26
 • Mail your written appeal to the Division of Child Welfare Licensing, P.O.

Box 30650, Lansing, MI 48909. You should obtain some type of delivery

confirmation to verify delivery;

• Fax your written appeal to the Division of Child Welfare Licensing at (517)

284-9719.

• Email your written appeal to DAUappeals@michigan.gov. You should

keep a copy of the sent email as proof of submittal.

LICENSEE IS FURTHER NOTIFIED that failure to file a written appeal of this

action within 30 days will result in revocation of the license.

DATED: 03/24/2021
Rachel Willis, Director
Division of Child Welfare Licensing
Department of Health and Human Services

This is the last and final page of a NOTICE OF INTENT in the matter of Wolverine Secure Treatment Center,
CI730201515, consisting of 27 pages, this page included.

KMM
 STATE OF MICHIGAN
DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF CHILD WELFARE LICENSING

In the matter of License #: CI730201515

Wolverine Secure
Treatment Center
Wolverine Secure Treatment Center

______________________________________/

NOTICE OF COMPLIANCE CONFERENCE

Date: April 12, 2021 Time: 2:00 to 4:00 p.m.

Location: TEAMS MEETING

Microsoft Teams meeting

Kelly Maltby has forwarded a Microsoft Teams appointment to your email address

Pursuant to the Administrative Procedures Act, MCL 24.292(1), you are afforded the
opportunity to attend an informal compliance conference. The purpose of the compliance
conference is to allow you to show that you were in compliance with the Child Care
Organizations Act and the licensing rules promulgated thereunder. You have the right, at your
expense, to have an attorney represent you at the compliance conference. You may also
bring one support person to the compliance conference.

To enable a thorough discussion of the Notice of Intent at the compliance conference, please
bring any documents, pictures, etc. that you would like the Department to consider. You may
also submit documents to the Department prior to the compliance conference by emailing
them to DAUappeals@Michigan.gov.

If you are unable to attend the compliance conference at the scheduled date and time, you
may request, in writing, that the Department change the date and/or time. The Department
will make all reasonable attempts to accommodate your request, but will not reschedule the
compliance conference to a date more than 10 days after the scheduled date. If you promptly
notify the Department of your inability to attend the compliance conference as scheduled, the
Department may be able to schedule the compliance conference to a date earlier than
originally scheduled.
If you are unable to show that you were in compliance with the Child Care Organizations Act
and licensing rules, and a resolution cannot be reached, the Department will forward the
matter to the Michigan Administrative Hearing System for the scheduling of a formal
administrative hearing. The Michigan Administrative Hearing System will subsequently notify
you of the date, time, and location of the administrative hearing.

All Department meetings and hearings are conducted in compliance with the Americans with
Disabilities Act in buildings that accommodate mobility-impaired individuals and have
accessible parking. If you require additional accommodations to participate in the compliance
conference, please notify the Department at least one week in advance to make the necessary
arrangements.

Please direct all written communications regarding the compliance conference or

administrative hearing, including your license number, to the individual listed below:

Kelly Maltby
Division of Child Welfare Licensing
Michigan Department of Health and Human Services
235 S. Grand Ave., Suite 407
P.O. Box 30650
Lansing, MI 48909
 STATE OF MICHIGAN
DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF CHILD WELFARE LICENSING

In the matter of License #: CI730201515

Wolverine Secure
Treatment Center
Wolverine Secure Treatment Center

______________________________________/

PROOF OF SERVICE

The undersigned certifies that a copy of a Notice of Intent to revoke the license in the above
matter was served upon the following person by mailing the same to them at their address
of record by certified mail on March 24, 2021.

Judith Fischer-Wollack
15100 Mack Avenue
Grosse Pte. Park,, MI 48231

Amy Fedewa, Secretary

Division of Child Welfare Licensing