Investigation Report 1

STATE OF MICHIGAN
GRETCHEN WHITMER DEPARTMENT OF HEALTH AND HUMAN SERVICES ELIZABETH HERTEL

GOVERNOR L ANSING DIRECTOR
March 17, 2021
Paul Whitney
Wolverine Human Services
15100 Mack Ave.
Grosse Pte. Park, MI 48231
RE: License #: CI730201515

Investigation #: 2021C0325012
Wolverine Secure Treatment Center
Dear Mr. Whitney:
Attached is the Special Investigation Report for the above referenced facility. Due to the
severity of the violations, disciplinary action against your license is recommended. You
will be notified in writing of the department’s action and your options for resolution of this
matter.
FOR CWL ONLY

Please note that violations of any licensing rules are also violations of the ISEP and
your contract.
Please review the enclosed documentation for accuracy and contact me with any
questions. In the event that I am not available and you need to speak to someone
immediately, please contact the local office at (989) 758-2717.
Sincerely,
Venus M. Decker, Licensing Consultant

MDHHS\Division of Child Welfare Licensing
411 Genesee
P.O. Box 5070
Saginaw, MI 48605
235 SOUTH GRAND AVENUE • PO BOX 30037 • LANSING, MICHIGAN 48909
www.michigan.gov/mdhhs • 517-241-3740
(248) 639-9585
611 W. OTTAWA • P.O. BOX 30664 • LANSING, MICHIGAN 48909

www.michigan.gov/lara • 517-335-1980
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enclosure
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MICHIGAN DEPARTMENT OF LICENSING AND REGULATORY
AFFAIRSBUREAU OF COMMUNITY AND HEALTH SYSTEMS
SPECIAL INVESTIGATION REPORT
I. IDENTIFYING INFORMATION
License #: CI730201515
Investigation #: 2021C0325012
Complaint Receipt Date: 01/19/2021
Investigation Initiation Date: 01/19/2021
Report Due Date: 03/20/2021
LicenseeName: Wolverine Human Services
LicenseeAddress: 15100 Mack Ave.

Grosse Pte. Park, MI 48231
LicenseeTelephone #: (313) 824-4400
Administrator: Judith Fischer-Wollack, Designee
Licensee Designee: Judith Fischer-Wollack, Designee
Name of Facility: Wolverine Secure Treatment Center
Facility Address: 2424 N Outer Drive

Saginaw, MI 48601
Facility Telephone #: (989) 776-0400
Original Issuance Date: 09/01/1997
License Status: 2ND PROVISIONAL
Effective Date: 02/08/2021
Expiration Date: 08/07/2021
Capacity: 100
Program Type: CHILD CARING INSTITUTION, PRIVATE
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II. ALLEGATION(S)
Violation
Established?
Youth A was restrained by Supervisor 1 and Supervisor 2. Yes
Supervisor 1 punched Youth A and Supervisor 2 choked Youth A.
Youth A had bruising on her face.
Youth B was restrained by Supervisor 1 and Supervisor 2. Both Yes
Supervisor 1 and Supervisor 2 punched Youth B. There are no
marks.
Additional Findings Yes
Staff does not have the ability to provide care for the youth at the Yes
facility.
The agency did not complete seclusion forms when youth were in Yes
seclusion.
The agency did not complete 15-minute checks on youth while Yes
they were out of the sight of staff
The agency did not report suspected child abuse and neglect as Yes
mandated by law.
The agency did not provide medical attention to Youth A and Yes
Youth B when necessary.
III. METHODOLOGY
01/19/2021 Special Investigation Intake

2021C0325012
01/19/2021 Special Investigation Initiated - Telephone
01/28/2021 Contact - Face to Face

Interviews with DHHS Social Service Worker and staff
01/28/2021 Contact - Document Received

reviewed initial video from a secondhand video.

reviewed personnel files.
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01/28/2021 Contact - Telephone call made.
PC interview with staff

incident reports, medical reports, logging received.

Interviews with DHHS Social Service Worker and BV Police with
staff

reviewed video from actual video surveillance.

PC to Administrator

Interviews with DHHS Social Service Worker and BV police with
staff and youth

Interviewed staff.

Attempted to review video; was stopped by VP.
02/09/2021 Contact - Telephone call received.

Administrator 1 called to report I could watch the video in his office
after already leaving the facility. Date for video set up for 2/17/21.

VM to staff
02/10/21 Interviews
Interview with staff
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02/21/21 Interviews
02/16/2021 Inspection Completed-BCAL Sub. Non-Compliance
03/05/2021 Received additional documentation
ALLEGATION:
Youth A was restrained by Supervisor 1 and Supervisor 2. Supervisor 1 punched Youth
A. Supervisor 2 choked Youth A. Youth A had bruising on her face.
Youth B was restrained by Supervisor 1 and Supervisor 2. Both Supervisor 1 and

Supervisor 2 punched Youth B. There are no marks.
INVESTIGATION:
The allegations address three separate restraints. Due to the multiple restraints, each
restraint will be addressed separately in the report. They will be addressed as Incident
1, Incident 2 and Incident 3.
Video surveillance was observed for all three restraints.
The investigation was conducted with DHHS Social Service Supervisor. Buena Vista
Police Department was present for some interviews and will be documented below in
those interviews. Currently, there is an open investigation with Buena Vista Police
Department.
The following documents were reviewed throughout the investigation:

• WHS Incident Reports
• Covenant Healthcare documentation
• Seclusion documents
• Buena Vista Police Report
• Personnel files
• Post Brief Forms (Life Space Interviews and Post Staff Debrief Forms)
• ICMP (Individual Crisis Management Plan)
• BSM Policy and Procedure for TCI in Residential Programs”:
• Child Protection Law policy
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Incident 1: Youth A was restrained by Supervisor 1 and Supervisor 2. Supervisor 1 punched
Youth A. Youth A had bruising on her face.
I reviewed the Incident Report dated 1/17/21 for Incident 1.

The incident is documented as occurring at 12:55pm on 1/17/21 and was submitted on
1/18/21 at 3:46pm. The incident report noted Youth A was not injured and did not need
to see medical personnel.
[Youth A] was put into a full team restraint to protect herself as well as
others...ran out of the unit several times running around and going to the boy’s
unit and banging on the door and breaking handles off of doors for weapons
saying she was going to kill [Supervisor 1] and [Supervisor 2]. She began to go at
[Supervisor 2] in an aggressive way by swinging a door handle at him saying she
was going to kill him. She was finally caught and placed in a team restraint.
During the restraint she was spitting and biting [Supervisor 1.]
I reviewed the SST ( Safety Support Team) log book for 1/17/21.
…off focus since they woke up, started breaking door handles and running off the
unit…several times had door handles swinging at [Supervisor 2], so we took her
down…
I reviewed the video surveillance for Incident 1 dated 1/17/21:
12:47:17: Youth A and Youth B are out in the gym area running around.
12:52:00: Youth A attempting to get into a door.
12:52:10: Youth A side-stepped to get away from Supervisor 2, Supervisor 2 is walking
towards Youth A and places his hands-on Youth A. Youth A attempts to swing her right
arm at Supervisor 2.
12:52:14: Supervisor 1 runs from behind Youth A and jumps off the ground and jumps
on Youth A’s back and has his arm around Youth A’s shoulder/neck area. Youth A falls
to the floor.
12:53:39: Supervisor 2 is on his knees on the gym floor. Youth A’s head is in between
Supervisor 2’s knees.
12:53:48: Supervisor 1 is on Youth A’s right side. Supervisor 2 is now on Youth A’s left
side and Supervisor 3 is holding and laying on Youth A’s legs. Supervisor 1’s right
elbow comes down in a quick motion towards Youth A and his body follows.
12:58:00: Youth A gets up from restraint.
It is to be noted that video surveillance does not show Youth A resisting the restraint. It
does not show Youth A swinging a doorhandle at Supervisor 2 before Supervisor 2
places his hands on Youth A.
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I reviewed the Buena Vista Township police report dated 2/17/21:
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While [Supervisor 1] has his knees on her (Youth A) right arm, [Supervisor 1] can
be seen driving his elbow to what appears to be the face of [Youth A] but the
claimed bite prior to the strike was not able to be seen on camera.
I received an email from DHHS Social Service Worker. An on-call workerinterviewed

Youth A on 1/18/21. The following is the interview:
Youth A provided the following information: She is 15 years old African American female
that resides at Wolverine Human Services Buena Vista location. Youth A’s appearance
was neat and clean wearing green sweatpants and sweatshirt. Youth A was in shackles
to restrict her movement and to prevent from running away. She did have noticeable
marks and/or bruises on her person. Youth A did have a black eye (left eye) with some
broken blood vessels in her eye.
Youth A was asked if she understood the difference between a truth and a lie. Youth A
reported she did. Youth A was then asked if walls on hospital were painted black.
Youth A reported that was a lie. Youth A was asked if she did not know any answer to a
question, she can state she does not know. Youth A was asked if she knew if my dog’s
name was George. Youth A reported she did not know. The ground rules were
established, and Youth A provided the following information through forensic
interviewing:
The allegations were read to Youth A who reported that it was all true. Upon meeting
with Youth A’s black eye was observed under her left eye with blood vessels broken in
eye. Youth A reported that she got restrained by staff and they punched her in eye and
elbowed her in the eye as well. Youth A reported the incident occurred due to her
running out her unit which is a secure unit. Youth A reported that she felt sick in her
unit, hot in her unit West B. Youth A reported she left unit and was in the gym area.
Youth A reported while she was in the gym area another resident tried to talk to her to
help her make better choices. Youth A reported that she then proceeded to go to her
therapist office where she stated, “You guys are not doing anything for me.” Youth A
reported that she then went into another classroom that was locked and broke the door
handle and proceeded to enter classroom. Upon entry of classroom Youth A reported
she called the master control room where she told them she need them to contact 911
to get her help. Youth A reported she was breaking the door handle off and head metal
pieces in her hand and staff took them from her. Youth A reported she then proceeded
to walk back to her unit but refused to go back in because it was too hot.
Youth A reported she felt someone push her from the back and fell to the ground.
Youth A reported she did not know if she blacked out from hitting the floor and does not
remember. Youth A reported she remembers Supervisor 2 having his knee on top of
her making it hard for her to breathe. Youth A reported that Supervisor 1 told her to
“Shut the Fuck up before I hit you” Youth A reported she stated to Supervisor 1 “why are
you doing this? I am not resisting.” Youth A reported she is moving around trying to get
staff off of her and Supervisor 2 eventually moved off of her and moved to the side of
her after 5 minutes. Youth A reported Supervisor 1 looked to both sides as a looking to
see if anyone was around and looking for cameras and hit her two times in the face then
elbowed her in the eye. Youth A reported Supervisor 3 was holding her legs down at
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the time and stated, “this is what happens when you don’t shut up.” Youth A reported
that Supervisor 2 told her that “it could have been worse.”
Youth A reported after this incident that nobody came to check her eye or give her any
medical attention/care.
I conducted a follow up interview on 2/21/21 with DHHS Social Service Worker. Youth
A reported she had felt pressure on her head and shoulders during the restraint. Youth
A reported she felt their knees on her shoulders during the restraint.
The following interviews were conducted with DHHS Social Service Worker andBuena Vista
Police Department when noted.
I interviewed Staff 1 via telephone on 2/10/21. Staff 1 reported being on duty on the unit
with Youth A, B, C and D. Youth A, B, and C began running around the unit eventually
running to the gym area. Staff 1 reported requesting help during this time, however no
one came to assist her. Staff 1 reported once Youth A, B, and C ran into the gym area,
she remained on the unit with Youth D. Staff 1 reported not knowing who supervised
Youth A, B, and C as they ran around the gym. Staff 1 reported a staff, (unnamed)
brought Youth B and C back to the unit. Staff 1 reported upon their return, Youth B
stood at the unit door and stated, “We gotta help her (Youth A).” Staff 1 reported she
heard Youth A screaming, “You gonna talk to me like that? You gonna let them do that
to me?” Staff 1 reported she did not see the restraints, which occurred in the gym.
Staff 1 reported, Youth A stated, upon re-entering the unit that Supervisor 1 and
Supervisor 2 kneed and punched her in the face and choked her while they were in the
gym. Staff 1 reported at that time, she observed that Youth A had a swollen and red
eye. Staff 1 reported Youth A stated, they (Supervisor 1 and Supervisor 2) had their
knees on her arms during the restraint to hold her down. While in the unit, Staff 1
reported Supervisor 1, Supervisor 2, and Supervisor 3 followed her around the unit.
Staff 1 reported Youth A was threatening stating, “On my dead brother, I will hurt them.”
Staff 1 reported Supervisor 3 then mimicked her and stated, “On my dead brother”. Staff
1 reported this came off as a threatening statement. Staff 1 reported there was a lot of
profanity between Youth A and Supervisor 1, Supervisor 2, and Supervisor 3.
I interviewed Supervisor 3 on 2/02/21 face to face with DHHS Social Service Worker
and Buena Vista Police Department. Supervisor 3 reported she did not see any of the
restraint because her eyes were closed during the restraint. Supervisor 3 reported that
she broke a nail during the restraint; therefore, was in pain, and had her eyes closed.
(Via the video, the restraint lasted over five minutes).
When Supervisor 3 was questioned on what her job duties were while she was on a
restraint, she reported it was to be aware of the other staff and the youth. Supervisor 3
then reported that she did not have her eyes closed the whole time but had some
awareness. Supervisor 3 reported Youth A and Youth B were running around the gym.
Supervisor 3 reported Youth A was restrained by Supervisor 1 and Supervisor 2 and
she went down with them to the floor. Supervisor 3 reported she was on Youth A’s legs
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and did not see anything out of the ordinary. Supervisor 3 reported Youth A stated, “She
was going to beat all our asses”. Supervisor 3 reported Supervisor 1 and Supervisor 2
had Youth A’s arms between their legs during the restraint. Supervisor 3 reported they
were not holding her arms down with their hands.
and Buena Vista Police Department. Supervisor 1 reported when Youth A was in the
gym, Youth A was breaking door handles and verbally threatening him. Supervisor 1
reported Youth A “squared up” to Supervisor 2 and Supervisor 1 ran up behind Youth A
in an attempt to knock the weapon out of her hand. The weapon fell and they fell to the
ground as well. Supervisor 1 reported this technique was called a “Wolverine Assist”.
The “Wolverine Assist” is the jumping from behind Youth A to restrain her. This can be
seen on the video at 12:52:14. Supervisor 1 reported he has discussed this “technique”
with other supervisors as well as Trainer 1. Supervisor 1 reported he had his hands on
her shoulders and then Youth A bit his left wrist. Supervisor 1 reported when she bit his
left wrist, he retracted his left arm and his right forearm landed on Youth A’s chest.
Supervisor 2 reported he has a herniated disc in his back and his back “gave way”
during this movement. Supervisor 1 reported he had his knees around Youth A’s arms
but not placed on her arms during the restraint. Supervisor 1 reported he did not punch
Youth A. Supervisor 1 confirmed Supervisor 2 and Supervisor 3 were also on the
restraint. Supervisor 1 reported he was given the “green light” to restrain Youth A if
need be. (“Green light” meant permission to restrain.) Supervisor 1 reported he was not
aware of what the other staff on the restraint were doing. When asked about
awareness of specific identified treatment modalities or past traumas that may impact
how Youth A should be handled; Supervisor 1 reported he does not know if Youth A has
any past traumas or past history. Supervisor 1 reported he did not know what was in
Youth A’s ICMP or Speed map which are tools identified by the facility to help Youth A
with her challenging behavior.
**It is to be noted the video surveillance does not show Supervisor 1 retracting his arm.
I interviewed Staff 2 on 2/16/21 via telephone. Staff 2 was an extra staff that assisted
with Incident 3 in the unit. Staff 2 was in the unit helping when Youth A entered the unit
from Incident 1 and Incident 2. Staff 2 reported Youth A entered the unit and you can
definitely tell there was something wrong with her eye. Staff 2 reported it looked like she
was just hit by someone in the eye. Staff 2 reported it was red. Staff 2 reported Youth B
stated Supervisor 1 hit her in the eye. Staff 2 reported this appeared to be true due to
the appearance of her eye.
I interviewed Staff 3 on 2/02/21 with DHHS Social Service Worker. Staff 3 was an extra
staff that assisted with Incident 3 in the unit. Staff 3 was in the unit helping when Youth
A entered the unit from Incident 1 and Incident 2. Staff 3 reported Youth A, Youth B and
Youth C had gotten out of the unit and were running around the gym area, breaking
door handles. Staff 3 reported Supervisor 1 and Supervisor 2 were in the gym area with
Youth A. Supervisor 1 was talking to Youth A as he came toward her, grabbing Youth
A’s shoulders. Staff 3 reported Supervisor 1 came from behind Youth A and wrapped
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his arms around her and took Youth A to the ground. Staff 3 reported she was escorting
Youth B back to the unit while this was occurring. Staff 3 reported Youth B was yelling
about Youth A’s restraint. Staff 3 reported when Youth A came back into the unit, she
was pacing and crying. Staff 3 reported she saw popped red blood vessels in her eye.
Staff 3 reported she worked the following day in the unit. Youth A told her at that time
that Supervisor 1 punched her in the eye. Staff 3 reported she just finished TCI training.
Staff 3 reported she was not taught to come from behind a youth to restraint them like
Supervisor 1 did. Staff 3 reported although TCI (Therapeutic Crisis Intervention) training
did not teach coming from behind to restrain a youth, she thought it was okay for them
to restrain Youth A that way because Youth A was bigger in size. Staff 1 acknowledged
she would not know how to restrain a youth that was bigger in size by using what she
was taught in training.
I interviewed Therapist 1 on 2/02/21 with DHHS Social Service Worker. Therapist 1

reported Youth A came to the office and told her that Supervisor 1 punched her in the
face and kicked her in the face as well. Therapist 1 reported there were two different
restraints mentioned. Youth A told Therapist 1 she was punched in the face during the
first restraint. Youth A told her that she was restrained a second time by the unit door
and someone kicked her in the face. Therapist 1 reported she did have bruising on her
face near her cheekbone and stated Youth A complained about blurred vision. Therapist
1 reported Youth A stated they made a comment about her deceased brother. Therapist
1 reported Youth B told her she was restrained in her bedroom and her head hit on the
bed as well as was punched by one of the staff. Therapist 1 reported she could not
remember what staff Youth B had said allegedly punched her.
I interviewed Staff 4 on 2/02/21 with DHHS Social Service Worker. Staff 4 reported she
did not see the restraint in the gym but did see Youth A later in the day on 1/17/21. Staff
4 reported she did not see any puffiness or redness in or around Youth A’s eye.
I interviewed Administrator 1 via telephone on 2/3/21. Administrator 1 reported

Supervisor 1 reported to him that during the restraint he was bit on the wrist and then
readjusted his arm on the restraint. Administrator 1 reported Supervisor 1 reported
Youth A may have hit her head on the ground.
Supervisor 2 did not show up for his interview.
I interviewed Youth B with the DHHS Social Service Worker on 2/02/21. Youth B
reported she was in the therapist office trying to call her mother. Youth B reported she
then had to leave the therapist office and go to the unit. While she was walking from the
therapist office to the unit, Youth B reported Supervisor 1 had his knees on Youth A’s
head. Youth B reported she saw Supervisor 1 punch Youth A with a closed fist in the
face. Youth B reported Supervisor 1 used his right fist. Youth B reported when Youth A
came into the unit, she stated she was just punched by “them”.
I interviewed Youth C with the DHHS Social Service Worker on 2/02/21. Youth C
reported she was in the gym area when they restrained Youth A. Youth C reported
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Youth A was backing away from Supervisor 2, saying “Don’t touch me”, when
Supervisor 1 came from behind and grabbed her. Youth C reported they picked her up
by her legs and “slammed” her to the ground. Youth C reported she returned to the unit
before Youth A. Youth C reported standing by the unit door upon Youth A’s return to the
unit when she observed Youth A to have swollen and blood shot eyes. Youth C reported
Staff 1 stated she was going to call CPS.
I interviewed Youth D with the DHHS Social Service Worker on 2/02/21.Youth D

reported she went into her room with the door locked for most of the day because she
did not want to get involved in the incident or hurt by the other youth. Youth D reported
when she went to the restroom, Youth A came into the unit. Youth D reported she
observed Youth A crying with a red and swollen eye. Youth D reported she went into
her room and locked the door.
DHHS Social Service Worker interviewed Staff 5, via telephone on 2/17/21. Staff 5 was
an extra staff that assisted with Incident 3 in the unit. Staff 5 was in the unit helping
when Youth A entered the unit from Incident 1 and Incident 2. The following is the
interview: Staff 5 was asked if she saw Youth A that evening (1/17/21). She confirmed
she did. Staff 5 said Youth A was not put in her room, she went into her room herself.
Staff 5 said when she saw Youth A she did see her face. Staff 5 said it looked like
Youth A had a blood clot in her eye. She was asked if Youth A told her how it
happened. Staff 5 said Youth A told her she was hit in the face. Staff 5 said Youth A
was talking so fast. She can’t say for sure who but Youth A told her it was Supervisor 1
or Supervisor 2 that did it.
She said that the staff then charged her and one of them
shoved their knee on her chest and brought her to the ground. She states that she did
hit the back of her head on the ground but did not lose consciousness. She also states
that while she was on the ground she kept talking after they asked her to stop talking
and when she did not, they punched her in the left eye.
See
photo.
On 1/18/2021 at 7:15:00 pm, the On call DHHS Social Service Worker spoke to
Video surveillance related to Incident 2: at 1:04:01 shows youth A constantly

touching her left eye.
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Incident 2: Youth A was restrained by Supervisor 1 and Supervisor 2.Supervisor 2 choked
Youth A. Youth A had bruising on her face.
Supervisor 2 did not cooperate with the interview process. Supervisor 3 did not show up
for his interview.
I reviewed the Incident Report dated 1/17/21 at 12:55pm related to Incident 2.
Youth A became physically aggressive again with SST. She started to swing with
closed fists. Youth A was placed in a team restraint. Supervisor 1 initiated the
non-violent physical intervention with the assistance of Supervisor 2 and
Supervisor 3…client refused the LSI (Life Space Interview). There were no
injuries, and no medical attention was required.
I reviewed the video surveillance dated 1/17/21 for Incident 2. The incident beganat 1:00pm:
*It is to be noted this restraint takes place up against the outside door/wall of the unit.
1:00:00: Youth A walking towards her unit door.

1:00:28: Youth A is putting her tennis shoes on.
1:00:29: Supervisor 2 tries to grab the second tennis shoe from Youth A; Youth A
pushes Supervisor 1 away from her.
1:00:31: Supervisor 2 wraps his arms around her waist, Supervisor 1 has his arms
around Youth A’s neck
1:00:33: Supervisor 1 loosens his hold and Youth A starts to fall towards ground
(against the wall)
1:00:35: Youth A is on the floor.
1:00:38: Supervisor 2 has his left hand on top of Youth A’s left side of face. Supervisor 3
is holding on to Youth A’s legs.
1:00:45: Supervisor 2 is crawling across Youth A’s face. Supervisor 2’s right knee is on
Youth A’s face
1:00:47: Supervisor 2’s right foot is in Youth A’s face.
1:00:48: Supervisor 1 is on Youth A’s right side, Supervisor 2 is on Youth A’s left side
and Supervisor 3 is on Youth A’s legs, Supervisor 1 moves Youth A’s hands and places
his knees on top of her hands.
I received an email from DHHS Social Service Worker. An interview was conducted by
DHHS Social Service Worker on 1/18/21. The following is theinterview:
Youth A reported she got up and then proceeded to go to the boy’s side of placement
where she knows there are cameras. Youth A reported that Supervisor 2 told her, “all
you are going to give me is unemployment if you tell.” Youth A reported that she then
proceeded to her unit where she went to put on her shoes to fight staff for what they did
to her. Youth A reported she was restrained again. Youth A reported that Supervisor 2
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“crawled” on her by placing his his knee on her face and chest. Youth A reported at this
time she felt her eye was bleeding from being hit. Youth A reported Staff 3 said she was
going to talk to Administrator 1 due to how they handled the situation and restrained
her. Youth A reported once she was in her unit that Supervisor 2 followed her around.
Youth A reported that she was mad and ran out the unit again and was in the gym area
breaking items and was trying to get into a classroom to call police or her mom. Youth
A reported that she eventually went back to her unit where Supervisor 2 and Supervisor
1 stated, “it’s a green light for everyone and we are gonna fuck you guys up.” Youth A
reported that at this time Supervisor 2 assaulted another peer and fell and hit her head.
and Buena Vista Police Department. Supervisor 3 reported she had “80%” awareness
of this restraint. Supervisor 3 reported Youth A had gotten up from Incident 1 and
walked over to the unit door. As she was walking over to the unit door, Youth A was
verbally threatening Supervisor 1. Supervisor 2, and Supervisor 3. Youth A grabbed her
tennis shoes and then placed her first shoe on her foot. Youth A then started to put on
her other tennis shoe. Supervisor 1 reported they then restrained her. Supervisor 1
reported that when Youth A was putting her tennis shoes on, she was showing signs of
physical aggression; therefore needed to be restrained. Supervisor 3 reported if Youth A
could get her tennis shoes on, then she would have better grip on the floor to fight.
Supervisor 1 reported this was part of TCI (Therapeutic Crisis Intervention). Supervisor
3 reported Youth A did not resist the restraint. Supervisor 3 reported Supervisor 2 had
to crawl over Youth A’s face and chest area, but never touched her while doing this.
Supervisor 3 reported she uses CBT (Cognitive Behavior Therapy) to deescalate youth.
Supervisor 3 did not know what CBT stood for. Supervisor 3 reported she will talk to the
youth and let them vent. Supervisor 3 stated she will also do worksheets and use the
Speed map. Supervisor 3 reported she did not have these forms to use at the time of
the restraint.
and Buena Vista Police Department. Supervisor 1 reported they let Youth A up from
Incident 1, and then she ran to get her shoes. While she was getting her shoes, she
was verbally threatening Supervisor 1, Supervisors 2, and Supervisor 3. Supervisor 1
reported Supervisor 2 grabbed Youth A’s shoe before she could put it on. Supervisor 1
reported they are permitted to grab weapons out of a youth’s hand if they intend to use
them to hurt others. Supervisor 1 reported it was okay to grab the shoe out of her hand
during the “outburst stage” because the shoes would give Youth A more grip on the
floor to fight. Supervisor 1 reported this is taught in TCI. Supervisor 1 reported during
this restraint he grabbed Youth A’s shoulders from behind and never grabbed her neck.
Supervisor 1 reported they twisted and fell to the ground. Supervisor 1 reported
Supervisor 2 had to climb over Youth A’s head and chest but never touched her.
Supervisor 1 reported they got into the right positions and held Youth A’s arms with their
knees, by placing them on both sides of her arms. Supervisor 1 reported Youth A never
complained about being hurt from the two restraints.
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A follow up interview was conducted with Youth A on 2/02/21. Youth A reported
Supervisor 2 was crawling over her face during the restraint and his knee went into her
face and chest. In the unit, Supervisor 1 and Supervisor 2 were following her around so
she went onto the tile and removed her shirt. Youth A reported she removed her shirt
and went on the tile because male staff could not go on the tile that leads into the
bathroom.
I interviewed Youth B on 2/2/21. Youth B reported she was in the unit next to the door
when Youth A was restrained by the door and wall. Youth B reported Youth A was
“slammed” against the door.
I interviewed Trainer 1, face to face on 2/9/21. Trainer 1 reviewed the tape of Incident 1
and Incident 2. Trainer 1 reported the way they restrained on the video is not the way he
trains TCI in training. 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
reported he has not trained a “Wolverine Assist” as Supervisor 1 reported.
Incident 3: Youth B was restrained by Supervisor 1 and Supervisor 2. Both

Supervisor 1 and Supervisor 2 punched Youth B. There are no marks.
I reviewed video surveillance for Incident 3.
Incident 3 video surveillance does not show the inside of the bedroom; therefore, I was
unable to view this. The following staff were in the unit in one capacity or another:
Supervisor 1, Supervisor 2, Staff 2, Staff 3, Staff 4, Staff 5, Staff 6, Staff 7, Staff 8
I reviewed the Incident Report for Incident 3 dated 1/17/21 at 2:43pm.
On 1/17/12 at 2:43pm, Youth B was put into a protective intervention and staff
had to get sharp objects from her and also a broken DVD’s she had. The objects
were remove and Youth B was placed in her room with staff doing fifteen minute
checks on her. SSTS initiated the non-violent physical intervention. The control
techniques was in place for approximately one minute. The letting go process
was good. SSTs performed the LSI at 2:45pm with a plan for her to take time
away and sit at her door. There was no injuries, and no medical attention was
necessary.
I reviewed the WHS Incident Report dated 1/19/21 at 9:27am.
Client reporting headache and bumps on head after incidents that occurred this
weekend.
14
she was tackled by staff, she notes that she hit her chin on
the ground and became dazed…she thinks another body part did hit her in the head as
well..
On 1/20/21, DHHS Social Service Worker interviewed Youth B. The following is theinterview.
A visit was made to Wolverine Secure Treatment Center to verify the well- being ofYouth
B. Youth A walked into the office wearing a black tshirt and green shorts.
She was not forensically interviewed at this time due to the need to coordinate with
licensing and law enforcement. Youth B said
She
said she was told she has to be careful and she cannot exercise right now.
Youth B was advised that this worker would be back to talk with her with a licensing
consultant about the incident and what happened. Youth B said she saw Supervisor 1
today and she does not feel safe with him still working in the facility. She denies that
Supervisor 1 or Supervisor 2 have worked with her again since the situation but states
she has saw them out of her window. She said she doesn't feel safe with them being in
the facility at all. Youth B pointed out Supervisor 1 who was across the gym. She said
he punched her in the eye and caused her to be dizzy. She said he also put his knee in
her neck. Youth B said Supervisor 2 also punched her with a closed fist. Youth B said
she lost consciousness after the incident. Youth B said they were on her chest
She said she was telling them she could not breathe. Youth B said she as
tackled on her bed, hit, punched her then slammed her to the ground.
Youth B said she and Youth A were running around the gym, (referring to Incident 1).
She said at first staff were joking with them. She said they then tackled Youth A.
Supervisor 1 squeezed Youth A’s head with his legs and elbowed her in the eye. Youth
B said she wants to tell "the state" everything that happened because that day there
were two dirty restraints, (referring to Incident 1 and Incident 2) She said Supervisor 1
and Supervisor 2 told her that Administrator 2 had given them the “green light” or
permission to restrain. She then saw a staff that she identified as Supervisor 3, an SST.
She said Supervisor 3 was there too during the restraints.
A follow up interview was conducted with Youth B on 2/4/21 with DHHS Social Service
Worker. Youth B reported she was placed into her room. Supervisor 1 came into her
room and grabbed her shirt by the chest area and then let her go, causing her to fall on
15
the bed. Supervisor 2 was in the room. Youth B reported someone kneed her in the
head and then put their knee on her chest and someone was trying to hold her hands.
Youth B reported Supervisor 1 punched her on the forehead. Youth B reported she fell
to the floor and laid on the ground. Youth B reported Staff 6 was in the room and
“popped” her bra. Youth B reported her breasts were no longer in her bra. Youth B
reported she hit the back of her head when they tossed her to the ground. Youth B
reported Staff 4 and Staff 5 checked on her when she was locked in the room. Youth B
reported Staff 5 let her out of her room later.
On 2/17/21, the DHHS Social Service Worker interviewed Staff 5 by telephone.
Staff 5 confirmed that she stood in the doorway of Youth B’s room once she was put in
the room. Staff 5 said Supervisor 1 and Supervisor 2 went in Youth B’s room because
Youth B had something on her and staff were trying to get it away. Staff 5 said she
thinks it was a CD. Staff 5 said a female staff also went into double check on Youth B
because she was just lying on the floor like she was “passed out or dead.” Staff 5 was
asked if Youth B had to be restrained in her room or what was going on. She said one
of the male staff had Youth B’s arms and one had her legs. She said the female staff
went in after. She said it really wasn’t a restraint at first. Staff 5 was asked where
Youth B was at in her room. She said at first she was on the bed then the floor. She
was asked how Youth B got to the floor and she said, “She put herself there.” Staff 5
denies that she saw anyone hit or elbow Youth B. Staff 5 denies that she saw Youth B
hit her head on anything when she went from the bed to the floor. Staff 5 said it wasn’t
until after that Youth B told her she hit her head on the corner of the bed. Staff 5 denies
that she saw any marks on Youth B following the incident. She said a few days later
Youth B reported she had a knot on her head. Staff 5 confirmed that she saw a knot on
Youth B’s forehead. She said Youth B told her it was from hitting her head on the bed.
I interviewed Staff 6 with DHHS Social Service Worker on 1/28/21. Staff 6 reported she
was getting ready to leave her shift around 2:30pm on 1/17/21 when Supervisor 1 and
Supervisor 2 asked for help in the Endeavors B unit. Staff 6 reported she went into the
unit to help where Youth A and Youth B were targeting Supervisor 1 by name calling
him. Youth A went into her room and the door was locked. Youth B was in her room
already. Staff 6 reported it was stated Youth B may have something in her room to do
self-harm, so they opened the door. Staff 6 reported Supervisor 1 and Supervisor 2
went into the room. Youth B was standing at the end of her bed and Supervisor 1 stood
in front of her. Then Youth B sat down on her bed. Staff 6 asked permission from Youth
B to perform a body check on Youth B. Staff 6 was referring to checking Youth B’s bra
and waistband of her shorts. Youth B refused. Staff 6 reported Youth B balled up in the
fetal position on her bed. Supervisor 1 then grabbed Youth A’s right arm and pulled to
the side. Staff 6 then pulled Youth A’s sports bra forward to look for any weapons.
Youth B got loose and balled back up. Staff 6 reported she tried to “pop” Youth B’s bra
again but could not. Staff 6 reported Supervisor 1 and Supervisor 2 then tried to grab
her arms and pull them to the side so she can “pop” Youth B’s bra. Staff 6 reported she
was unable to do this so they left the room. Youth B then threw a compact disc and
metal piece out the door. They then shut and locked her door. Staff 6 reported staff
16
(unnamed staff) reported Youth A had a string in the room, so they opened the door
back up and was able to get the string. They shut the door and locked it placing her in
seclusion. Staff 6 reported Youth C and Youth D were in their rooms the entire time.
Staff 6 reported she was unsure why they were in there. Staff 6 reported Youth A was
crying in her room. Staff 6 stated this was normal behavior for Youth B but not Youth A.
I interviewed Staff 7 with DHHS Social Service Worker on 1/28/21. Staff 7 reported she
was getting ready to leave her shift when she noticed Youth A and Youth B running
around in the gym by themselves with broken door handles. Staff 7 reported she went
up front to find other staff. Staff 7 reported Supervisor 1, Supervisor 2, Staff 6, Staff 8,
Staff 3 all went into the gym. Supervisor 1 and Supervisor 2 escorted Youth A and
Youth B into the unit. Youth A went into her room. Youth B went into her room, but Staff
6 needed to check her bra for weapons. Youth B refused to let them check her so
Supervisor 1 and Supervisor 2 had grabbed her arms and she was laying on her back
half on her bed and half on the floor. Staff 7 reported Staff 6 checked her bra and
waistband and found a Compact disc and a minor string. Staff 7 reported they did not
restrain her. Staff 7 reported she did not see Youth A hit her head. Staff 7 reported
Youth A was not resisting them holding her. Staff 7 reported they then shut the door and
locked it. Staff 7 reported Staff 4 and Staff 5 were the second shift staff that evening.
I interviewed Staff 2 on 2/16/21 via telephone. Staff 2 reported seeing Supervisor 1 and
Supervisor 2 push Youth A on the bed to restrain Youth A. Staff 2 reported they pushed
her and used their body weight to get her on the bed. Staff 2 reported Supervisor 1 had
one knee on the bed and one leg off the bed. Supervisor 1 was on the left side of the
bed. Staff 2 reported Supervisor 2 had both his knees on the bed and they were both
holding Youth A down. Staff 2 reported “he came down quick with his elbow” and “he
was slick about it”. Staff 2 was told to clarify this and reported Supervisor 1, in a quick
motion, elbowed Youth A. Staff 2 reported he did not see where on her body, Youth A
was elbowed but reported Youth A began to cry and later reported (after the restraint
was over) to Staff 2 that she (Youth A) was hit in the face. Staff 2 reported after Youth A
was elbowed, they pulled her off the bed and held her down in a three-man restraint.
Staff 2 reported Youth A went to the floor without fighting and did not hit her head on the
floor or the bed. Staff 2 reported Staff 3 removed something from Youth A’s sports bra
band. Staff 2 reported in their opinion, this situation did not rise to the intervention of a
restraint.
I interviewed Staff 1 on 2/10/21 via telephone. Staff 1 reported the following day, Youth
B told her they threw her around in the room and she hit her head. Staff 1 reported
observing Youth B’s forehead, near her eyebrows, were puffed up and red. Staff 1
reported she had Youth A and Youth B go see Therapist 1 so that they could tell her
what happened. Staff 1 reported Administrator 1 and Administrator 2 came to the unit
and asked them about the incident and both youth told them the same story.
went to help on the unit with Youth A and Youth B. Staff 8 reported Youth A and Youth
17
B were both crying and name calling Supervisor 1, Supervisor 2, and Supervisor 3.
Youth A went into her room and the door was locked. Staff 8 reported Youth B went into
her room and they had to “pop” her bra because she might have a weapon. Staff 8
reported, she, Staff 6, Staff 7 helped remove the weapon from her bra. Staff 8 reported
someone moved her arms so that they could “pop” her bra. Staff 8 reported there was
not a restraint. Staff 8 reported she has not received clear training on how to complete
body checks on the youth. Staff 8 reported she did not hear any staff yelling or using
profanity at Youth A or Youth B.
had been in the unit to help with Youth A and Youth B. Staff 4 reported Youth B had a
weapon on her. Youth B was in her room and Supervisor 1 and Supervisors 2 as well as
Staff 6 and Staff 7 were in the room. Supervisor 1 and Supervisor 2 placed Youth B in a
restraint and then Staff 6 checked Youth B’s bra for a weapon. Youth B was resisting
the restraint and cussing and yelling at them. Staff 2 reported Staff 6 put her hands
down the front of Youth B’s shirt and removed screws, a broken spork, and a small
metal piece. After they retrieved these items, Youth B was laying on the floor quietly.
Supervisor 1 stated, “She is alright”. The door was shut and locked. After the
Supervisors left, Youth A did get up from the floor and complained of her head hurting.
Staff 4 observed Youth B had a knot near her left eyebrow.
had been on the unit to help with Youth A and Youth B. Staff 3 reported Youth B was
refusing to go into her room. Staff 3 reported Youth B was stating, “You guys should
have seen what they done to Youth A.” Staff 3 went into her room and then Supervisor
1 and Supervisor 2 went in as well. Staff 3 reported someone grabbed Youth B’s hands
and made her sit on the bed. Staff 3 reported Youth B ended up on the floor but, she did
not see how this happened. Staff 3 reported Youth A was laying on her back on the floor
and Supervisor 1 had both her hands held down and Supervisor 2 had both Youth B’s
legs held down. Staff 3 reported she was not resisting. Staff 3 reported she did not see
what happened next, but they did leave her room and shut the door and locked it. The
following day, 1/18/21, Staff 3 reported the nurse came and saw her. Staff 3 reported
observing Youth B had a knot on her face and the nurse gave her ice.
I interviewed Supervisor 1 on 2/2/21 with DHHS Social Service Worker. Supervisor 1

reported Youth B was in her room and Supervisor 1, Supervisor 2 and Staff 6 went into
the room. Supervisor 1 reported Youth B had a broken compact disc, and they needed
to retrieve this. Supervisor 1 reported they (Supervisor 1 and Supervisor 2) grabbed
Youth B’s arms and then held her wrists down on the bed. Supervisor 1 reported Youth
A’s legs were straight out off the bed. Supervisor 1 reported Staff 6 placed her hand
down the shirt of Youth B and grabbed the compact disc. Supervisor 1 reported Youth B
then went to the floor on her butt and just sat there. Supervisor 1 reported they left the
room, close the door and it was locked. Supervisor 1 reported Youth B never mentioned
she was hurt. Supervisor 1 reported he was taught to talk to the youth to remove a
weapon from them. Supervisor 1 reported he was also taught to “do what is necessary
to grab weapon”. Supervisor 1 reported this would mean grabbing a youth’s arm or wrist
18
to retrieve the item. Supervisor 1 reported he does not know Youth A’s trauma history,
past history, what is in her ICMP (Individual Crisis Management Plan) or Speed Map.
Supervisor 1 reported this was not his usual “corner” to monitor.
I reviewed “The BSM Policy and Procedure for TCI in Residential Programs”:
…the focus is to provide immediate emotional and environmental support to

clients in crisis so that stress and the risk for violence are reduced. Secondly,
the focus is to teach clients more constructive, effective ways of dealing with
stress and painful feelings so that the future risk for violence is reduced.
…Non-violent physical intervention is defined as a staff member’s use of physical
control to contain a client’s acute physical behavior… These interventions are
non-violent and are to be used in such a manner as to not be hostile or
injurious…
The use and choice of all non-violent physical interventions must be guided by a
number of factors including the following:
• The need to ensure safety of other clients and staff.
• The client’s Individual Crisis Management Plan (ICMP).
I reviewed Youth A’s ICMP. The ICMP is an assessment used to help the child
manage emotions and behaviors. According to TCI Student Workbook, “With this plan in
place, teams can address prevention of problematic situations, the teachings of
alternative skills, responses to crisis intervention…” Youth A’s ICMP documents: “Are
there any health restrictions for TCI Physical management? Has asthma”
I reviewed the TCI Student Handbook
5.2 Safety Concerns: situations in which restraint-while indicated-should be

avoided would include: When the child or young person has a weapon that could
cause serious injury, we should clear the area. It is extremely dangerous to try to
restrain someone who is holding a weapon. The risk of someone being injured is
tremendous…(Page S57)
Improper Restraint Methods that Pose a Risk to Injury or Death:

Is it exceedingly dangerous to apply any pressure to a young persons neck…any
restraint that limits the normal process of expansion and contraction of the chest
also poses a risk of asphyxia. This would include sitting or applying weight to a
young person’s chest, back…while the young person is laying down…(Page
S60)
The LSI after the Restraint: The LSI should take place away from the location
where the restraint occurred and when the young person is calm enough that
talking about the situation will not end up in another loss of control (S66)…when
the child refuses to talk…making an appointment to talk again in a half-hour or
when the young person is ready may give the young person the space and time
needed (S67)…
19
Personnel files were reviewed for Supervisor 1 and Supervisor 3.
Both were current in training required.
Supervisor 1 was hired on 9/28/16 as a youth care worker.

Supervisor 1 had the following Employee Counseling Forms:
• 8/3/17: One day suspension: “communicating with a client in care’s sister via
face book
• 10/15/17: Warning: “failed to properly debrief 3rd shift resulting in him taking East
B unit keys home”
***Supervisor 1 received a promotion and became a SST
• 5/14/18: Written Warning: failure to arrive to work.

• 7/12/18: Written Warning: violated policy 5: Sexual and other harassment
prevention policy which states, “Unwelcomed sexual advances, requests for
sexual favors, or other verbal or physical conduct of a sexual nature, constitutes
sexual harassment when…”
• 7/20/18: Warning: failed to attend job training.
• 8/28/18: Warning: failed to distribute medications to clients on East A and East B
• 9/12/18: Warning: failed to maintain proper supervision on his assigned units.
• 11/6/18: Suspension (3 days): …left the facility and went to the corner store
without proper relief during his assigned shift, which left his assigned corner
without proper line of sight…
• 2/20/19: Warning: failed to report to a mandated shift.
• 2/22/19: Written Warning: did not arrive to shift.
• 4/9/19: Warning: failed to give client his morning insulin which resulted in the
client’s blood glucose levels to be high.
• 7/23/19: Warning: found smoking in the parking lot
***Performance Evaluation completed 7/1/19:

The following areas Supervisor 1 has received a “4” out of “5”. The scale is rated from
1-5. One being “poor” and five being “excellent”.
• Follows safety rules and guidelines as established in policies and procedures.
• Performs tasks and duties in a timely manner and effective manner…
• Demonstrates knowledge and competence related to the characteristics and
needs of the clients…
The following areas Supervisor 1 received a “3” out of “5”:
• Builds trust by respecting the ideas and contributions of everyone; works well
with others. Supports and assists others on a regular basis, contributes to
positive moral…
20
Supervisor comments: …will work on training staff in being proactive and work on
CBT core skills. Counseling checkbox not checked by supervisor.
• 8/23/19: Suspension (1 day): failed to complete wellness corrections in the SST

log and to complete shift observation section of SST logbook.
• 12/11/19: Suspension (1 day): failed to pass medication to clients in South and
East units
• 12/24/19: Written warning: did not arrive to work.
• 2/7/20: Written Warning: left the facility without all 2nd shift SST’s arriving for
their shift, resulting in only two SST’s managing the floor.
• 5/19/20: Suspension (3 day): used mechanical restraints in appropriately
(handcuffed child to a bed)

• Attendance is followed in accordance with policy. Dependable, follow schedules,
attends all meetings and trainings.
The following areas Supervisor 1 has received a “4” out of “5”. Follows safety rules and
guidelines as established in policies and procedures.
positive moral…
• Supervisor comments: works well with troubled clients, always helps out with the
site, great team work. Counseling form checkbox is not checked by supervisor.
I reviewed the Shift Supervisor Team Member’s job description.
Supervises all Youth Care Workers on their shift, by providing direction,

guidance, and implementation of Therapeutic Crisis Intervention and Cognitive
Behavioral Theory interventions with clients.
Maintain control and security of the facility, while applying Therapeutic Crises
Intervention and Cognitive Behavioral Theory interventions to various client
circumstances.
Function as a mandated reporter, as required by Michigan Child Protection Law.
21
APPLICABLE RULE
Rule 1 Prohibition of Prone Restraint; Procedures Involving Other
Restraints in Child Caring Institutions
(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.
ANALYSIS There are three restraints that occurred. All three restraints were
not performed in a manner that was safe, appropriate or
proportionate to the child’s behavior.
Incident 1:
• Video surveillance reveals Supervisor 1 running from
behind Youth A and jumping on the back of Youth A to
restrain her
• Supervisor 1 placed his knees on or on the side of Youth
A’s arms to hold them in place
• Supervisor 2 placed Youth A’s head between his knees
• The BSM Policy and Procedure for TCI in Residential
Programs was not followed.
22
ANALYSIS Incident 2:
CONTINUED • Supervisor 1, Supervisor 2, and Supervisor 3,
: restrained Youth A due to her verbal threats and the
action of putting her shoes on. This restraint was not
performed in a manner proportionate to the severity of
the child’s behavior.
• Youth A was restrained in close proximity to a wall.
• Supervisor 1 grabbed Youth A by her neck/shoulder
area to restrain her.
• Supervisor 2 wrapped his arms around her waist to
restrain her.
• Supervisor 2 climbed over Youth A’s face and chest
areas to get into position due to the limited space.
• Supervisor 1 was unaware of Youth A’s and Youth B’s
ICMP although The BSM Policy and Procedure for
TCI in Residential Programs states the ICMP is to
be used as a factor to guide the Non-violent physical
intervention.
Incident 3:
• There were a total of eight staff involved in Incident 3.
Seven of the staff were there to witness the incident.
Each staff gave a different account of the incident;
although all eight reported some sort of restraint or
holding down of Youth B’s arms. The restraint was not
done in a safe manner. The restraint started on the
bed and ended on the floor. The restraint was not
conducted by three staff and does not follow the The
BSM Policy and Procedure for TCI in Residential
Programs.
•
• Youth B reported she was punched in the face and

Staff 2 reported Supervisor 1 hit Youth B with his
elbow.
• Staff 1, Staff 3, and Staff 4 all reported Youth B had a
knot on her forehead that day or the following day.
23
CONCLUSION: REPEAT VIOLATION ESTABLISHED (repeat violation
include for R400.4159 old restraint rule)
2020C0325009: INTAKE 10/1/19 CAP approved 12/20/19
APPLICABLE RULE
R 400.158 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.
ANALYSIS Supervisor 1 inflicted corporal punishment onto Youth A

and Youth B.
• Youth A and Youth B reported Youth A was punched in

the face. Video surveillance shows a right elbow comes
down in a quick motion towards Youth A during the
restraint. Medical documentation, police report, and
interviews support this.
• Staff 1, Staff 2, Therapist 1, Youth C, and Youth D all
report observing some sort of redness, puffiness or
bruising around or in Youth A’s eye.
• Youth B reported she was punched in the face.
• Staff 2 reported “he came down quick with his elbow”
and “he was slick about it”. Staff 2 was told to clarify this
and reported Supervisor 1, in a quick motion, elbowed
Youth B.
•
• Staff 1, Staff 3, and Staff 4 all reported Youth B had a

knot on her forehead that day or the following day.
24
CONCLUSION: REPEAT VIOLATION ESTABLISHED
2021CO325004: INTAKE 11/15/20 CAP approved 3/25/21
ADDITIONAL FINDINGS: Supervisor 1, Supervisor 2, and Supervisor 3do not

have the ability to perform the functions of their assigned positions.
INVESTIGATION:
APPLICABLE RULE
R 400.4112 Criminal history check, subject to requirements; staff
qualifications.
(4) A person with ongoing duties shall have both of the

following:
(a) Ability to perform duties of the position assigned.
ANALYSIS Supervisor 1, Supervisor 2, and Supervisor 3 demonstrated an

inability to perform the functions of their assigned positions. It is
a part of Supervisor 1, Supervisor 2, and Supervisor 3’s job
functions to apply Therapeutic Crises Intervention and Cognitive
Behavioral Theory interventions to various client circumstances
but yet they did not perform those functions.
• Supervisor 1 did not use interventions to ensure the

safety of the youth in his care. Supervisor 1 has an 18
Employee Counseling forms from 8/3/17 to present day.
This history shows repeated violations of policies ranging
from not showing up for his shift to leaving and placing
youth in an unsafe situation.
25
ANALYSIS • Supervisor 2 reported she did not have her eyes open for
CONTINUED: a five-minute restraint (Incident 1) she was actively a part
of. Then reported she had some awareness. Supervisor
2 did not report the inappropriate restraint techniques to
her supervisor. Supervisor 3 did not know what CBT
stood for and associated it with completing forms.
• Supervisor 3 did not cooperate with the licensing

investigation. Supervisor 3 did not use interventions to
ensure the safety of the youth in his care. Supervisor 3
did not report the inappropriate restraint to his supervisor.
REPEAT VIOLATION ESTABLISHED

ADDITIONAL FINDINGS: The RCC, Residential Care Coordinator did not adhereto the job
description outlined.
INVESTIGATION:
I reviewed the Residential Care Coordinator (RCC) Job Description:
• Supervise Safety and Support Team (SST)

• Coordinate development of SST with the Director of Staff Development and
Program Manager.
Therapist 1 and Human Resources reported via email that the RCC would be responsible
for the completion of the SST’s performance evaluations.
Supervisor 1 was hired on 9/28/16 as a youth care worker.

Supervisor 1 had the following Employee Counseling Forms:
• 8/3/17: One day suspension: “communicating with a client in care’s sister via
face book
• 10/15/17: Warning: “failed to properly debrief 3rd shift resulting in him taking East
B unit keys home”
***Supervisor 1 received a promotion and became a SST
• 5/14/18: Written Warning: failure to arrive to work.
26
• 7/12/18: Written Warning: violated policy 5: Sexual and other harassment
prevention policy which states, “Unwelcomed sexual advances, requests for
sexual favors, or other verbal or physical conduct of a sexual nature, constitutes
sexual harassment when…”
• 7/20/18: Warning: failed to attend job training.
• 8/28/18: Warning: failed to distribute medications to clients on East A and East B
• 9/12/18: Warning: failed to maintain proper supervision on his assigned units.
• 11/6/18: Suspension (3 days): …left the facility and went to the corner store
without proper relief during his assigned shift, which left his assigned corner
without proper line of sight…
• 2/20/19: Warning: failed to report to a mandated shift.
• 4/9/19: Warning: failed to give client his morning insulin which resulted in the
client’s blood glucose levels to be high.
• 7/23/19: Warning: found smoking in the parking lot

• Follows safety rules and guidelines as established in policies and procedures.
The following areas Supervisor 1 received a “3” out of “5”:
positive moral…
Supervisor comments: …will work on training staff in being proactive and work on
CBT core skills. Counseling checkbox not checked by supervisor.
• 8/23/19: Suspension (1 day): failed to complete wellness corrections in the SST

log and to complete shift observation section of SST logbook.
• 12/11/19: Suspension (1 day): failed to pass medication to clients in South and
East units
• 12/24/19: Written warning: did not arrive to work.
• 2/7/20: Written Warning: left the facility without all 2nd shift SST’s arriving for
their shift, resulting in only two SST’s managing the floor.
• 5/19/20: Suspension (3 day): used mechanical restraints in appropriately
(handcuffed child to a bed)

27
• Attendance is followed in accordance with policy. Dependable, follow schedules,
attends all meetings and trainings.
The following areas Supervisor 1 has received a “4” out of “5”. Follows safety rules and
guidelines as established in policies and procedures.
positive moral…
• Supervisor comments: works well with troubled clients, always helps out with the
site, great team work. Counseling form checkbox is not checked by supervisor.
APPLICABLE RULE
R 400.4111 Job Description
(1) An institution shall provide a job description for each

staff position that identifies rules, required
qualifications, and lines of authority.
ANALYSIS:
This rule requires the facility to develop a job description which
delineates the lines of authority. The expectation is that the
employee will adhere to the job description. Awareness of
responsibility is acknowledged by the signature on the job
description.
The job description states for Residential Care Coordinator

states, the Residential Care Coordinator will coordinate
development of SST with the Director of Staff Development and
Program Manager. Performance Evaluations were completed
on Supervisor 1. Supervisor 1 received good to excellent on all
work performance categories, despite numerous write-ups. The
Residential Coordinator did not give an accurate assessment of
his performance, and there is no documentation to support that
there was any effort to coordinate his development as a SST
with the Program Manager. His negative performance was not
addressed on the performance evaluation.
CONCLUSION: VIOLATION ESTABLISHED
ADDITIONAL FINDINGS: The agency is not following the behavior management

system outlined in their program. The agency is using
28
terms and actions not outlined in the current behavior managementsystem.
INVESTIGATION:
I interviewed Trainer 1, face to face on 2/9/21. Trainer 1 reviewed the tape of Incident 1
and Incident 2. Trainer 1 reported the way they restrained on the video is not the way he
trains TCI in training. 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
reported he has not trained a “Wolverine Assist” as Supervisor 1 reported. (The
Wolverine Assist is the jumping from behind to restrain). Trainer 1 reported the following
techniques as “protective interventions.”
• Protective stance: open hands low by waist outstretched and positioned a “kick”
distance away, taking steps away from the youth
• Bites: push into bite or “feed” the bite
• Hair pulls: place hand on top of the youths hand pulling your hair and “rake” your
hair/hand out of the position, making sure to go with the youth as they move
• A youth grabs your hands: grab the youths hands and twist and pull your arm
from them
• Chokes (youth chokes staff): Staff are to place their hands straight up and twist
back to the protective stance
• Youth trying to punch staff: Staff are to use forearms to block then back to
protective intervention
5.2 Safety Concerns: situations in which restraint-while indicated-should be

avoided would include: When the child or young person has a weapon that could
cause serious injury, we should clear the area. It is extremely dangerous to try to
restrain someone who is holding a weapon. The risk of someone being injured is
tremendous…(Page S57)
I interviewed Administrator 1 on 1/28/21. Administrator 1 reported he was told by

Supervisor 1 and Supervisor 2 that they placed Youth B in seclusion. Due to her having
a broken compact disc, they used a protective intervention, attempting to hold her arms,
to retrieve the compact disc.
I interviewed Staff 3 on 2/21/21. Staff 3 reported she just finished TCI training. Staff 3
reported she was not taught to come from behind a youth to restraint them like
Supervisor 1 did during Incident 1. Staff 3 reported she thought it was okay for them to
restrain Youth A that way because Youth A was bigger in size. Staff 1 acknowledged
she would not know how to restrain a youth that was bigger in size by using what she
was taught in training.
29
I interviewed Supervisor 3 on 2/21/21. Supervisor 3 reported she uses CBT to
deescalate youth. Supervisor 3 did not know what CBT stood for. Supervisor 3 reported
she will talk to the youth and let them vent. Supervisor 3 stated she will also do
worksheets and use the Speed map. Supervisor 3 reported she did not have these
forms to use at the time of the restraint.
I interviewed Supervisor 1. Supervisor 1 reported they are permitted to grab weapons

out of a youth’s hand if they intend to use them to hurt others. Supervisor 1 reported it
was okay to grab the shoe out of her hand during the “outburst stage” because the
shoes would give Youth A more grip on the floor to fight. Supervisor 1 reported this is
taught in TCI. Supervisor 1 reported he did not know what was in Youth A’s ICMP or
Speed map. Supervisor 1 reported Youth A “squared up” to Supervisor 2 and
Supervisor 1 ran up behind Youth A in an attempt to knock the weapon out of her hand.
The weapon fell and they fell to the ground as well. Supervisor 1 reported this technique
was called a “Wolverine Assist”. Supervisor 1 reported he has discussed this
“technique” with other supervisors at the agency as well as with Trainer 1. Supervisor 1
reported he does not know if Youth B has past trauma history. Supervisor 1 reported he
does now know what is in Youth B’s ICMP or speed map. Supervisor 1 reported he
used a protective intervention on Youth B when they held her arms to retrieve the
compact disc. Supervisor 1 stated grabbing a youth by the arm or wrist to retrieve an
object is a protective intervention.
I reviewed the Incident Report dated 1/17/21 at 2:43pm for Youth B. The incident report was
written by Supervisor 3.
…Youth B was put in a protective intervention and staff had to get sharp
objects from her…SST’s initiated the non-violent physical intervention…
APPLICABLE RULE
R 400.4157 Behavior Management
(2) An institution shall establish and follow written

policies and procedures that describe the institutions
behavior management system.
ANALYSIS Staff do not have knowledge of the behavior management
system.
• Administrator 1, Supervisor 1 and Supervisor 3 reported
a protective intervention was grabbing Youth B’s arms to
retrieve the compact disc. Trainer 1 provided the
definitions of protective interventions in his interview.
• Only one out of the seven staff involved in incident 3 did
not believe the bedroom restraint was warranted. All
seven staff did not report there was a problem with the
way they removed the compact disc from Youth B
30
although it was not done in a safe manner; half on bed,
half off bed and with two staff.
ANALYSIS • Staff have created a new “technique” to restrain and

CONTINUED: coined a term (Wolverine Assist) outside of the current
• Staff 3, although just completed a recent new staff
orientation, thought that a “Wolverine Assist” was okay to
do because the size of Youth A. Staff 3 observed this
“technique” by Supervisor 1.

ADDITIONAL FINDINGS: The agency did not follow the procedures for debriefingstaff and
youth after the restraints.
INVESTIGATION:
The LSI after the Restraint: The LSI should take place away from the location
where the restraint occurred and when the young person is calm enough that
talking about the situation will not end up in another loss of control (S66)…when
the child refuses to talk…making an appointment to talk again in a half-hour or
when the young person is ready may give the young person the space and time
needed (S67)…
… Following any incident involving non-violent physical intervention, the site

management will ensure that debriefing and support is offered to the client, the
staff members, and any other persons involved or witness to the incident.
Debriefings occurs in a safe, confidential setting as soon as possible following
the incident and includes the client(s) involved, a site supervisor, and personnel
31
involved…
32
Immediate debriefing of involved personnel and clients serves to:
1.Evaluate physical and emotional well-being of client and staff.
2. Identify the additional need for counseling, medical care, or other services
related to the incident
3. Identify precipitating behaviors and modify the clients service plan or ICMP as
appropriate; and facilitate the person's reentry into routine activities
Debriefing of the client(s) and staff is documented on agency form (Staff Post-Incident
Debriefing Form for staff and Life Space Interview for clients) and serves to assesstheir
current physical and emotional status, the precipitating events of the incident, evaluation of how
the incident was handled, and necessary changes to procedures and/or training to avoid future
incidents.
Incident 1 and Incident 2 Post Debriefing Forms:

I reviewed Youth A’s Life Space Interview (LSI) form. Youth A had two restraints that
occurred with Supervisor 1, Supervisor 2, and Supervisor 3. An LSI was not conducted.
The LSI was attempted. The LSI form states, “client refused”. The LSI form does not
state the time this was attempted or incident reference.
I reviewed Youth A’s Incident report for Incident 1 and Incident 2. The Incidentreport states:
Was a face-to-face youth debriefing held within 24 hours after the use of
personal restraint? “Yes”
I reviewed one Staff Post Incident Debriefing form. The form was completed by Supervisor 4.
The form was completed with Supervisor 3. There were no staff concernsand no follow up from
Supervisor 4 noted. Supervisor 4 is Supervisor 3’s co-worker.
Precipitating factors were reported as Youth A was frustrated there was not a nurse on
site. The response to the incident and improvement opportunities identified were “use
caring gestures to deescalate client”.
Supervisor 1 and Supervisor 2 did not have a Post Staff Incident Debriefing Form
completed.
I reviewed Youth A’s Incident report for Incident 1 and Incident 2. The Incidentreport states:
Was a staff debriefing held within 24 hours? “Yes”
Incident 3 Post Debriefing Forms:
I was provided an LSI for Youth B. It did not have the date, incident reference, staffname, or
time on the form. The form states, “client refused”
33
I reviewed Youth A’s Incident report for Incident 3. The Incident report states:
34
“SST’s initiated the non-violent physical intervention…SST’s performed the LSI at
2:45 with a plan for her to take time away and sit at the door.”
The agency was unable to provide staff debriefing forms for Incident 3.
APPLICABLE RULE
Rule 2 Prohibition of Prone Restraint: Procedures Involving Other
Restraints in Child Caring Institution
(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
ANALYSIS:
• Post Staff debriefing was not completed for Incident 1 or
Incident 2, with the exception of Supervisor 3. Although
this was completed, it was completed by her co-worker,
not her supervisor.
• Post staff debriefing was not completed for all staff
involved in Incident 3.
CONCLUSION: REPEAT VIOLATION ESTABLISHED (Rule 2 (specifically

debriefing) would have fallen under R.400.4157; therefore,
the following repeats are a from of R 400.4157)

2019 C0325063: INTAKE 9/17/19 CAP approved 1/13/20
35
APPLICABLE RULE
Rule 2 Prohibition of Prone Restraint: Procedures Involving Other
Restraints in Child Caring Institution
(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.
ANALYSIS: • Youth A’s post debriefing was not completed as per

behavior management policy.
• Incident 3 pertaining to Youth B reported an LSI was
completed at 2:45pm (two minutes after the restraint)
and the plan was her to sit at her door. An LSI reenters
the youth into the group. Youth B was still in seclusion
until approximately 3:15pm. If the youth could complete
an LSI at 2:45pm, she would no longer need seclusion
and should have be reentered into the unit.
• The LSI form for Incident 3 reported Youth B refused.
There are inconsistencies in reports written by the
agency.
• The following evaluations are not being completed due to
the post debriefing dorms not being completed: physical
and emotional well-being of client and staff. Identify the
additional need for counseling, medical care, or other
services related to the incident. Identify precipitating
behaviors and modify the clients service plan or ICMP as
appropriate; and facilitate the person's reentry into routine
activities.
CONCLUSION: REPEAT VIOLATION ESTABLISHED (Rule 2 (specifically

debriefing) would have fallen under R.400.4157; therefore,
the following repeats are a from R 400.4157)
2020C0325020: INTAKE 11/5/19

2020C0325011: INTAKE 10/31/19
2020C0106034: INTAKE 4/20/20
2020C0325063: INTAKE 9/17/19
2019C0325061: INTAKE 9/24/19
2019C0325023: INTAKE 2/1/19
2019C0325044: INTAKE 5/25/19
36
ADDITIONAL FINDINGS: Eye on checks were not completed for YouthC
and Youth D
INVESTIGATION:
While watching the video surveillance for Incident 1, 2, and 3, I observed Youth C and
Youth D in their room with the door shut. There were increments of time Youth C and
Youth D were not observed. Video surveillance was observed from 10:30am and ended
at 2:10pm. (Youth D was still in here room at 2:10pm)
Administrator 1 reported Youth D was in her room due to feeling unsafe during these
incidents. Administrator 1 reported she chose to be in her room.
Video Surveillance:
Youth C went into her bedroom.

10:53am: Youth C enters into her room and shuts door.
12:22:50pm: Staff 1 performs an eye on check with Youth C.
Youth D went into her bedroom.

10:30:00am: Youth D goes into her room and shuts the door.
10:52:00am: A staff unlocks the door for Youth D to use the restroom.
10:57:07am: Youth D goes back into her room and closes it.
12:04:46pm: Supervisor 3 performs an eye on check with Youth D.
12:13:31pm: Youth D comes out of her room.
12:14:34pm: Youth D goes back into her room.
12:49:37pm: Staff 1 performs an eye on check with Youth D.
The agency provided Non-Violent Physical Intervention Reports for Youth D. These
were used to track the eye-on checks completed while she stayed in her room.
One was completed for the times from 7:00am-8:00am. These checks were observed
through video surveillance. The second form was completed for 2:00pm-3:00pm. There
are no forms for the times above.
There were no forms completed for Youth C.
APPLICABLE RULE
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
37
interval, eye-on checks of residents. The time between the
variable interval checks shall not exceed fifteen minutes.
ANALYSIS: The agency did not perform variable interval, eye-on checks for
Youth C for one hour and twenty-two minutes.
The agency did not perform variable interval, eye-on checks for
Youth D for one hour and five minutes.
Technical Assistance There were two forms completed for

eye-on checks for Youth C and Youth D. These forms did not
encompass the entire time that Youth C and Youth D were in
their rooms.
The facility does not have an identified process or forms

monitoring youth when they go into their rooms voluntarily as
required by this rule. It is suggested that a form and process be
developed for the monitoring of youth who voluntarily place
themselves in their rooms.

ADDITIONAL FINDINGS: The forms were not completed for the following
areas: Youth B placement into seclusion, post debriefing staffforms, and post
debriefing youth forms.
INVESTIGATION:
While watching the video surveillance for Incident 1, 2, and 3, I observed Youth B,
Youth C and Youth D in their room with the door shut. There were increments of time
Youth B, Youth C, and Youth D were not observed by staff. Video surveillance was
observed from 10:30am and ended at 2:10pm. All seclusion documents were requested
due to lack or eye-on checks. While reviewing seclusion for Youth C and Youth D, I
observed Youth B placed into seclusion at 12:58pm.
Youth C and D were not placed in seclusion See Above ALLEGATION for findings
pertaining to Youth C and Youth D.
I interviewed Staff 4 on 2/2/21. Staff 4 reported Youth A and Youth B were placed into
seclusion. Staff 4 reported Supervisor 1, Supervisor 2, and Supervisor 3 had left the unit
at this time. Staff 4 reported she did not fill out a seclusion forms and did not have to log
anything pertaining to the seclusion. Staff 4 reported she was to check with one of the
38
Supervisors to let them out of the room. Staff 4 reported they were in the room for about
30-60 minutes.
I interviewed Supervisor 1 on 2/4/21. Supervisor 1 reported Youth B went into seclusion

after they removed the compact disc from her. Supervisor 1 reported they let her out of
seclusion within an hour. Supervisor 1 reported the unit staff would have logged the
time increments. Supervisor 1 reported Youth B came out of her room within the hour of
being placed into seclusion.
Youth A Seclusion:
Youth A did not have a Non-Violent Physical Intervention Report-Part A for seclusion
during the time frame after Incident 3 (@2:30pm)
There was a Non-Violent Physical Intervention Report-Part A document completed for

Youth A from 7:00-8:00. (Morning or afternoon is not documented)
The agency did not have a Post Staff Debrief form or LSI for Youth A.
Youth B Seclusion:
Video surveillance shows Youth B was placed into seclusion at 12:58:12pm-1:28:33pm.
The agency did not have a Non-Violent Physical Intervention Report-Part A documented
for this seclusion.
The agency did not have a Post Staff Debrief form or LSI for Youth B.
I reviewed the Incident Report for Youth B dated 1/17/21 at 2:43pm written bySupervisor
3.
…Youth B was placed in her room with staff doing fifteen-minute checks on her…
Youth B was in seclusion from 2:45pm-3:15pm.
The agency did not have a Post Staff Debrief form or LSI for Youth B.
I interviewed Administrator 1 on 2/9/21. Administrator 1 reported he did not provide

verbal approval for Youth B to be placed into seclusion at 2:45pm.
I reviewed “The BSM Policy and Procedure for TCI in Residential Programs”: Staff will
also enter the time of the observation per logging procedure and any unusual
observations must be documented on Non-Violent Physical Intervention Report Form,
Part B. The purpose of the 15-minute observation and review is to
39
determine a) whether the behavior of the client warrant continued confinement
and b) whether the client is safe from harm.
Following any incident involving use of a Seclusion Room, the staff will ensure
that debriefing procedure above is followed.
Debriefings occurs in a safe, confidential setting as soon as possible following

the incident and includes the client(s) involved, a site supervisor, and personnel
involved…
Immediate debriefing of involved personnel and clients serves to:

1.Evaluate physical and emotional well-being of client and staff.
2. Identify the additional need for counseling, medical care, or other services
related to the incident
3. Identify precipitating behaviors and modify the clients service plan or ICMP as
appropriate; and facilitate the person's reentry into routine activities
incidents.
incidents.
APPLICABLE RULE
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:
(e) Staff shall observe the resident at intervals of 15
minutes or less and shall record the observation in a
seclusion room log. Video surveillance shall not be
the only means of observation.
40
ANALYSIS: Youth B did not have seclusion documents for her placement
into seclusion at 12:58:12pm.
CONCLUSION: VIOLATION ESTABLISHED
APPLICABLE RULE
R 400.4157 Behavior Management
(3) An institution shall establish and follow written

policies and procedures that describe the institutions
ANALYSIS • The agency did not follow The BSM Policy and
Procedure for TCI in Residential Programs. Staff and
youth debriefing forms were not completed.
ADDITIONAL FINDINGS: Medical attention was not provided to Youth

A and Youth B after the Incident 1 and Incident 2.
INVESTIGATION:
Youth A Medical
The on call DHHS Worker provided these observations during her interview on 1/18/21.
She did have noticeable marks and/or bruises on her person. Youth A did have a black
eye (left eye) with some broken blood vessels in her eye.
I interviewed Staff 1 on 2/10/21. Staff 1 reported Youth A was escorted into the unit and
she had a swollen and red eye.
Supervisor 1 reported she did not have any marks or bruises on her after the restraints.
Supervisor 1 reported she did not receive any medical attention. Supervisor 1 reported
there is not a nurse or medical care on the weekends.
41
I interviewed Staff 2 on 2/16/21 via telephone. Staff 2 reported Youth A entered into the
unit and you can definitely tell there was something wrong with her eye. Staff 2 reported
it looked like she was just hit by someone in the eye. Staff 2 reported it was red.
I interviewed Therapists 1on 2/16/21 with DHHS Social Service Worker. Therapist 1
reported she did have bruising on her face near her cheekbone and stated Youth A
complained about blurred vision.
I interviewed Staff 4 on 2/16/21. Staff 4 reported she did not see any puffiness or
redness in or around Youth A’s eye.
Youth C reported when Youth A came into the unit she had swollen and blood shot
eyes. Youth C reported Staff 1 stated she was going to call CPS.
I interviewed Youth D with the DHHS Social Service Worker on 2/02/21. Youth D
reported when Youth A saw her she was crying and her eye was red and swollen.
DHHS Social Service Worker interviewed Staff 5, via telephone on 2/17/21. The
following is the interview: Staff 5 was asked if she saw Youth A that evening (1/17/21).
She confirmed she did. Staff 5 said it looked like Youth A had a blood clot in her eye.
I interviewed Youth A on 2/4/21 with DHHS Social Service Worker. Youth A reported
after she was restrained nobody came to check on her eye or give her any medical
attention/care.
There are no initial agency medical documents to review.
She said that the staff then charged her and one of them
shoved their knee on her chest and brought her to the ground. She states that she did
hit the back of her head on the ground but did not lose consciousness. She also states
that while she was on the ground she kept talking after they asked her to stop talking
and when she did not, they punched her in the left eye.
On 1/18/2021 at 7:15:00 pm, the On call DHHS Social Service Worker spoke to
42
A follow up medical was completed on 1/25/21 by Great Lakes Bay Health Centers
Wolverine Saginaw.
Youth B Medical
I reviewed the Incident Report for Incident 3 dated 1/17/21 at 2:43pm.
On 1/17/12 at 2:43pm, Youth B was put into a protective intervention and staff
had to get sharp objects from her and also a broken DVD’s she had. The objects
were remove and Youth B was placed in her room with staff doing fifteen minute
checks on her. SSTS initiated the non-violent physical intervention. The control
techniques was in place for approximately one minute. The letting go process
was good. SSTs performed the LSI at 2:45pm with a plan for her to take time
away and sit at her door. There was no injuries, and no medical attention was
necessary.
DHHS Social Service Worker interviewed Staff 5 on 1/20/21. Staff 5 denies that she
saw any marks on Youth B following the incident. She said a few days later Youth B
reported she had a knot on her head. Staff 5 confirmed that she saw a knot on Youth
B’s forehead.
I interviewed Staff 1 on 2/10/21 via telephone. Staff 1 reported Youth B’s forehead, near
her eyebrows, were puffed up and red. (This was observed on 1/18/21). Staff 1 reported
Administrator 1 and Administrator 2 came to the unit and asked them and both youth
told them the same story.
I interviewed Staff 4 on 2/2/21 with DHHS Social Service Worker. After the Supervisors
left, Youth A did get up from the floor and complained of her head hurting. Staff 4
reported Youth B had a knot near her left eyebrow.
I interviewed Staff 3 on 2/2/21 with DHHS Social Service Worker. The following day,
1/18/21, Staff 3 reported the nurse came and saw her. Staff 3 reported Youth B had a
knot on her face and the nurse gave her ice.
I reviewed the WHS Incident Report dated 1/19/21 at 9:27am.
Client reporting headache and bumps on head after incidents that occurred this
weekend.
Action taken: Client Transported to Covenant ER for evaluation
I reviewed the Covenant Health Care document dated 1/19/21 at 2:38pm.
43
she was tackled by staff, she notes that she hit her chin on
the ground and became dazed…she thinks another body part did hit her in the head as
well..
APPLICABLE RULE
R 400.4142 Health Services; policies and procedures
An institution shall establish and follow written health

service policies and procedures addressing all of the
following:
(1) Routine and emergency medical, and dental, and

behavioral health
.
ANALYSIS: The agency did not provide medical care to Youth A after
sustaining injuries to her eye from a restraint on 1/17/21 at
12:55pm. Staff 1, Staff 2, Therapist 1, Youth A, Youth B, and
Staff 5 all reported there was either bruising, redness, puffiness
on Youth A’s eye yet no medical attention was provided to
Youth A until 1/18/21 at in the evening. The agency did not
provide medical care to Youth B after sustaining injuries to her
head after a restraint on 1/17/21 at 2:43pm. Staff 1, Staff 3, Staff
4, Staff 5, and Youth B all reported either a knot or redness
around Youth B’s forehead/eyebrow area. Youth B was not seen
by the nurse until 1/19/21 at 9:27am.
On 2/21/21 Staff 1 reported she thought Youth A suffered abuse from Supervisor 1 and
Supervisor 2 after Incident 1 and Incident 1. Staff 1 reported she went to the front of the
building and told all the “higher ups” that what was going on was not right. Staff 1
reported she did not call or report the abuse herself. Staff 1 reported “everyone” knew
what was going on. Staff 1 reported she did not see the restraints. Staff 1 reported
Youth A was escorted into the unit and she had a swollen and red eye. Staff 1 reported,
Youth A was stating, when she entered into the unit, they (Supervisor 1 and Supervisor
2) kneed her in the face, chocked her, and punched her in the face. Staff 1 reported
Youth A stated, they (Supervisor 1 and Supervisor 2) had their knees on her arms
during the restraint to hold her down.
44
I interviewed Staff 2 on 2/16/21 via telephone. Staff 2 reported Youth A entered into the
unit and you can definitely tell there was something wrong with her eye. Staff 2 reported
it looked like she was just hit by someone in the eye. Staff 2 reported it was red. Staff 2
reported Youth B stated Supervisor 1 hit her in the eye. Staff 2 reported this appeared
to be true due to the appearance of her eye
On 2/21/21, Staff 2 reported when Supervisor 1 elbowed Youth B, it was not abuse.
Staff 2 was unable to define what abuse and neglect would be. Staff 2 reported the
agency did train them on abuse and neglect. Staff 2 reported the agency trained them to
step in and stop it and then report it to Administrator 1. Staff 2 reported not telling
anyone what happened to Youth B. Staff 2 wanted to ensure anonymity in the interview.
.
I interviewed Staff 3 on 2/02/21 with DHHS Social Service Worker. Staff 3 reported
when Youth A came back into the unit, she was pacing and crying. Staff 3 reported she
saw popped red blood vessels in her eye. Staff 3 reported she worked the following day
in the unit. Youth A told her at that time that Supervisor 1 punched her in the eye.
DHHS Social Service Worker interviewed Staff 5, via telephone on 2/17/21. The
following is the interview: Staff 5 was asked if she saw Youth A that evening (1/17/21).
She confirmed she did. Staff 5 said when she saw Youth A she did see her face. Staff
5 said it looked like Antionna had a blood clot in her eye. She was asked if Youth A told
her how it happened. Staff 5 said Youth A told her she was hit in the face. She can’t
say for sure who but Youth A told her it was Supervisor 1 or Supervisor 2 that did it.
I reviewed the Child Protection Law and Mandated Reporter policy andprocedures.
…must report within 24 hours to the Division of Child Welfare Licensing as well
as to Child Protective Services…WHS employees will report all forms of foster
parent and or employee imposed abuse or neglect that results in bruises
fractures, cuts or abrasions. If in doubt of whether to report or not, employees will
follow reporting guidelines and consult with the head of their department…care s
to be taken to guarantee the safety pf the child. Medical care…are to be provided
or arranged immediately…
Any staff member who observes another staff member, a volunteer, or a visitor
behaving in any prohibited manner must follow the reporting procedures outlined
by the State Mandated Reporting Rules in Child Protection Law. Appropriate
disciplinary action of staff (from counseling to dismissal) will be taken if violations
to this occur. Any staff member who had knowledge of another person violating
45
this policy and failed to report that information to a direct supervisor will be
subject to the same disciplinary action.
APPLICABLE RULE
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.
ANALYSIS: The agency did not report the suspected abuse and neglect
within 24 hours to Child Protective Services.
• Staff 1 reported she felt what happened to Youth A was

abuse. Staff 1 did not report this to CPS. Staff 1 reported
she did tell all the “higher ups” before she left her shift.
Staff 1 left before Incident 3 on 1/17/21.
• Staff 2 reported not thinking that the elbowing to Youth B
was abuse. Staff 2 reported not knowing what abuse
meant. Staff 2 was told by Youth A that she was punched
in the face by staff on 1/17/21. Staff 2 reported Youth A
looked like someone hit her in the face.
• Staff 5 reported working in the unit with Youth A that
evening and was told by Youth B that she was punched
by one of the supervisors. Staff 5 reported Youth A did
have a blood clot in her eye.
2021C0106015: INTAKE 1/26/21
2019C0325023: INTAKE 2/1/19
IV. RECOMMENDATION
I recommend revocation of the license.
3/5/21
Venus M. Decker Date

Licensing Consultant
46
Approved By:
Franchesca Vega
DCWL Administrative Manager
47
48

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STATE OF MICHIGAN

GRETCHEN WHITMER DEPARTMENT OF HEALTH AND HUMAN SERVICES ELIZABETH HERTEL

March 17, 2021

RE: License #: CI730201515

Dear Mr. Whitney:

FOR CWL ONLY

Venus M. Decker, Licensing Consultant

611 W. OTTAWA • P.O. BOX 30664 • LANSING, MICHIGAN 48909

Complaint Receipt Date: 01/19/2021

Investigation Initiation Date: 01/19/2021

Report Due Date: 03/20/2021

LicenseeName: Wolverine Human Services

LicenseeAddress: 15100 Mack Ave.

LicenseeTelephone #: (313) 824-4400

Administrator: Judith Fischer-Wollack, Designee

Licensee Designee: Judith Fischer-Wollack, Designee

Name of Facility: Wolverine Secure Treatment Center

Facility Address: 2424 N Outer Drive

Facility Telephone #: (989) 776-0400

Original Issuance Date: 09/01/1997

License Status: 2ND PROVISIONAL

Effective Date: 02/08/2021

Expiration Date: 08/07/2021

Program Type: CHILD CARING INSTITUTION, PRIVATE

01/19/2021 Special Investigation Intake

01/19/2021 Special Investigation Initiated - Telephone

01/28/2021 Contact - Face to Face

01/28/2021 Contact - Document Received

01/28/2021 Contact - Document Received

01/28/2021 Contact - Document Received

02/02/2021 Contact - Face to Face

02/02/2021 Contact - Document Received

02/03/2021 Contact - Telephone call made.

02/04/2021 Contact - Face to Face

02/08/2021 Contact - Face to Face

02/09/2021 Contact - Document Received

02/09/2021 Contact - Telephone call received.

02/09/2021 Contact - Telephone call made.

03/05/2021 Received additional documentation

Youth B was restrained by Supervisor 1 and Supervisor 2. Both Supervisor 1 and

Video surveillance was observed for all three restraints.

The following documents were reviewed throughout the investigation:

I reviewed the Incident Report dated 1/17/21 for Incident 1.

I reviewed the video surveillance for Incident 1 dated 1/17/21:

I received an email from DHHS Social Service Worker. An on-call workerinterviewed

I interviewed Therapist 1 on 2/02/21 with DHHS Social Service Worker. Therapist 1

I interviewed Administrator 1 via telephone on 2/3/21. Administrator 1 reported

Supervisor 2 did not show up for his interview.

I interviewed Youth D with the DHHS Social Service Worker on 2/02/21.Youth D

Video surveillance related to Incident 2: at 1:04:01 shows youth A constantly

I reviewed the Incident Report dated 1/17/21 at 12:55pm related to Incident 2.

1:00:00: Youth A walking towards her unit door.

Incident 3: Youth B was restrained by Supervisor 1 and Supervisor 2. Both

I reviewed video surveillance for Incident 3.

I reviewed the Incident Report for Incident 3 dated 1/17/21 at 2:43pm.

I reviewed the WHS Incident Report dated 1/19/21 at 9:27am.

On 2/17/21, the DHHS Social Service Worker interviewed Staff 5 by telephone.

I interviewed Supervisor 1 on 2/2/21 with DHHS Social Service Worker. Supervisor 1

…the focus is to provide immediate emotional and environmental support to

I reviewed the TCI Student Handbook

5.2 Safety Concerns: situations in which restraint-while indicated-should be

Improper Restraint Methods that Pose a Risk to Injury or Death:

Both were current in training required.

Supervisor 1 was hired on 9/28/16 as a youth care worker.