Elevations RTC Investigations

Elevations RTC
2650 West 2700 South, Syracuse, UT 84075 (Davis County)

(801) 773-0200
(53277) ISC - Intermediate Secure Care :Renewal: (05/31/2021)
Name of this Investigation:

* Start Date:
03/07/2017
* Lead Assignment:
-- Select Lead Assignment --
Licensor:Amanda Johnson
Entered By:System
Intake
Source:
Provider Incident Report (e.g., incident report)
Date of Incident:
Date Reported:
Notification: The provider reported within one business day.
Reported By:
Contact Info:
Summary of Issue:
youth was combative and physically aggressive with a broom towards staff. After several prompts to
stop, and a the physical aggression with the broom, was placed in a hold. He continued to be
combative, was fighting against staff, tripped over a mop bucket and fell to the ground, which resulted
in a broken wrist. Youth received a broken wrist from the fall during a hold immediately contacted the
nurse on shift and the PA on shift to evaluation wrist. It was immediately immobilized. The
therapist and parents were notified. He was immediately sent to the nearest emergency room
Clients Involved:
Licensees, Staff, and Witnesses Involved:
Licensee Follow-Up
Actions Taken by Licensee:
Actions Planned by Licensee:
Additional Comments:
Office Follow-Up
Investigate Within:
-- Select Investigate Within --
Priority Due Date:
Document Admin Staffing:
Date Priority Met:
QA Monitoring
Activity Log:
Add
Nothing found to display.
Documents:
Add
Violations:
Add
Update Status
Findings
* Critical Incident:
A critical incident occurred related to this Investigation.
Yes No
Sites Affected:
All Sites
Elevations RTC 2514 South 1300 West Syracuse, UT 84075
Elevations RTC1873 S. Bluffridge Dr. Syracuse, UT 84075
Conclusion Summary:
Finalized Date:06/30/2017

* Start Date:
06/05/2017
* Lead Assignment:
Entered By:Shawna Cales
Intake
Source:
Date of Incident:
Date Reported:
Reported By:
Contact Info:
Summary of Issue:
2 female youth sexually acting out: reported ID the therapist that she and another student had
tnuched each other's genital areas while sitting In the hallway on dorms In the evening of 6/5/17. She
reported the conlact happened under a blanket. reported that the other peer initiated the contact
and that she felt like she "muldn't say no" even though 5he was uncomfortable with the conlact
stated that after the peer stopped toodllng her that the peer grabbed her hand and guided It to the
peer's genitll areas where then IDUChed the peer.
Clients Involved:
.
Licensee Follow-Up
6/6/2017 7:00:00 PM
Therapist called and talked with both parents.
Kelly Richards
6/7/2017 2:00:00 AM 2347940
6/8/2017: Per investigation of event by , no breaches in policy or procedure
were found. The students were within eye sight of the staff members and other students. Neither
student was on any sort of safety precautions or additional supervision precautions. The students were
able to engage in sexual acting out behaviors due to lower bodies being covered by blankets.
Subsequent to the incident, staff have been directed to not allow students in close proximity to each
other to be fully or partially covered in blankets. Hands must be visible.
6/8/2017: Upon disclosure of incident to Primary Therapist (of both students), on
6/6/2017, was notified of the incident and the allegation of sexual abuse/assault per policy and
procedure. indicated that the report was of routine urgency and that a safety check and interview
would take place on campus within 3-5 days. Additionally, the Primary Therapist initiated a safety plan
to keep the two students separated. Student, was scheduled for discharge from the program on or
before 6/30/2017. The safety plan would remain in place throughout that time.
6/15/2017: completed a safety check and brief interview with on 6/12/2017. An in-person
interview was requested and scheduled for 6/14/2017 by at the in
Farmington, UT. Student was transported to by Elevations staff on 6/14/2017 and interview was
completed.
6/27/2017: was interviewed by at on 6/14/2017. At that time
indicated that she would be interviewing on campus in the following weeks. interviewed
on 6/22/2017. After the interview indicated to primary therapist, , that
based on the interviews, the facts of the incident, and that parents were not interested in pursuing
charges, she did not anticipate the matter proceeding further in any way. Her decision regarding this
would be reviewed by her supervisory team by July 101h.
Office Follow-Up
Investigate Within:
Priority Due Date:
staffed with Janice and Jeff
Date Priority Met:
QA Monitoring
Activity Log:
Add
Documents:
Add
Violations:
Add
Update Status
Findings
Yes No
Sites Affected:
All Sites
Conclusion Summary:
no violations noted. Neither
student was on any sort of safety precautions or additional supervision precautions. The students were
able to engage in sexual acting out behaviors due to lower bodies being covered by blankets.
Subsequent to the incident, staff have been directed to not allow students in close proximity to each
other to be fully or partially covered in blankets. Hands must be visible.

* Start Date:
08/07/2017
* Lead Assignment:
Intake
Source:
Date of Incident:
Date Reported:
Reported By:
Judith Jacques
Contact Info:
jjacques@elevationsrtc.com
Summary of Issue:
Staff brought to nursing and stated he had fallen and hurt his wrist while playing capture the flag.
Another resident collided with hit the matted wall and fell to the ground. He supported his
fall with his left wrist
Clients Involved:

Jackie Harms
Cynthia Byerly
Licensee Follow-Up
was assessed by the nurse on staff, consultation occured with the PA, and was transported to
Tanner Clinic
Office Follow-Up
Investigate Within:
Priority Due Date:
Jeff and Janice Aug 8, 2017
Date Priority Met:
QA Monitoring
Activity Log:
Add
Documents:
Add
Date Name Comment
08/09/2017 broken wrist from playing capture the flag
Violations:
Add
Update Status
Findings
Yes
Type of Incident:
Serious Injury
Sites Affected:
All Sites
Conclusion Summary:
no violations noted. Accident and the program followed policy

* Start Date:
08/12/2017
* Lead Assignment:
Intake
Source:
Date of Incident:
Date Reported:
Reported By:
Contact Info:
Summary of Issue:
On 8/12/17 allegedly from her cell phone showed provocative images of her girlfriend in
what has been described as "a lacey see through bra." These images where shown to 3 students
was assigned to be supervising; , and .
Clients Involved:
Licensee Follow-Up
Program contacted Syracuse PD and The employee is on
unpaid administrative and will not be permitted to be on campus until the matter is resolved (at a
minimum).
Office Follow-Up
Investigate Within:
Priority Due Date:
Janice Weinman DHS
12:27 PM
to me, Jeffery
I would have them get the answer to that question.
Because there is a law enforcement investigation, it is a 10-day QA (that makes it a
critical incident with an alleged law violation) and you will need to follow up to get the final
determination of their investigation to see if any other rules were potentially violated and what the
agency does about this staff member before you close it. (Did this staff have a cleared BCI?) .
Janice Weinman
Date Priority Met:
QA Monitoring
Activity Log:
Add
Documents:
Add
Date Name Comment
08/15/2017 staff staff showed youth provocative images on her cell phone
Violations:
Add
Update Status
Findings
Yes
Type of Incident:
Other
Sites Affected:
All Sites
Conclusion Summary:

* Start Date:
10/18/2017
* Lead Assignment:
Entered By:Stephanie Robb
Intake
Source:
Date of Incident:
10/10/2017
Date Reported:
10/18/2017
Reported By:
Contact Info:
Summary of Issue:
Another student approached this writer and said that needed to disclose some information.
told this writer that another student had been touching his buttocks and crotch on top of his
pants and he did not want this to happen. At approximately 16:00 this writer again approached
and asked if there was any further information about the incident. disclosed that he "made out"
and gave the other peer a "blow job." This writer asked if this was forced and shared that he did
these actions willingly as a means to upset his parents and hope that they would pull him from the
program.
Clients Involved:

Licensee Follow-Up
The incident was reported by our therapist to was opened.
Office Follow-Up
Investigate Within:
No further assessment needed
Priority Due Date:
Jeff Harris administratively staffed this incident on October 27th, 2017. No further assessment is
needed as two youth engaged in sexually inappropriate behaviors. The youth who was questioned
indicated that he engaged in the acts as a way to have his parents remove him from the program. No
critical incident occurred and the staff appeared to have appropriately responded to the incident when
it was discovered. No licensing violations noted.
Date Priority Met:
QA Monitoring
Activity Log:
Add
Documents:
Add
Date Name Comment
10/18/2017 Sexual behavior
Violations:
Add
Update Status
Findings
No
Sites Affected:
All Sites
Conclusion Summary:
No further assessment is needed as two youth engaged in sexually inappropriate behaviors. The youth
who was questioned indicated that he engaged in the acts as a way to have his parents remove him
from the program. No critical incident occurred and the staff appeared to have appropriately responded
to the incident when it was discovered. No licensing violations noted.

* Start Date:
04/03/2018
* Lead Assignment:
Intake
Source:
Other Regulatory Agency (e.g., DCFS, JJS, Law Enforcement)
Reported By:
Contact Info:
Summary of Issue:
Hello,
So I processed a referral for a child (not in Utah's custody) who reported that he believes that a member
of the night staff at his treatment facility (Elevations, RTC) was having anal sex with him. I didn't see this
facility on the list of current State of Utah contracts, but thought I should still let you guys know.
Attached is the for the referral I processed.
Clients Involved:

Licensee Follow-Up
Office Follow-Up
Investigate Within:
Initiate investigation within 10 business days
Priority Due Date:
04/17/2018
Jeff Harris admin staffed this incident. Accusations were made that a male staff may have raped a
youth. will investigate
Review investigation when completed and determine if any licensing violations occurred. Currently
a critical incident due to the allegation of rape.
Date Priority Met:
QA Monitoring
Activity Log:
Add
Documents:
Add
Date Name Comment
04/03/2018 Allegations of sexual misconduct
Violations:
Add
Update Status
Findings
No
Sites Affected:
All Sites
Conclusion Summary:
concluded their investigation and Syracuse PD was contacted and involved in the investigation as
well. Both concluded that the incident was unsupported and further information is detailed in the
investigation. No licensing violations were noted and it is not a critical incident due
to the investigation finding that it was unsupported.

Suicide attempt-
* Start Date:
07/19/2018
* Lead Assignment:
Michelle Pierson
Intake
Source:
Date of Incident:
07/09/2018
Date Reported:
07/10/2018
Reported By:
Contact Info:
Summary of Issue:
Attempted suicide with glass from a calculator.
Clients Involved:

Licensee Follow-Up
Taken to the hospital via ambulance for stitches
Office Follow-Up
Investigate Within:
Priority Due Date:
08/03/2018
Jeff Harris admin staffed this incident. Determine if the youth met the criteria for admission into the
program. Ensure that staffing ratios were maintained at the facility. Program took appropriate actions
when notified that the youth had been self-harming. Document and finalize unless other issues are
noted.
Date Priority Met:
07/23/2018
QA Monitoring
Activity Log:
Add
Date Time Type Who
07/27/2018 03:56 Other Licensee Contact Michelle Pierson
07/23/2018 03:45 Other Licensee Contact Michelle Pierson
Documents:
Add
Date Name Comment
07/19/2018 Attempted suicide
Violations:
Add
Update Status
Findings
Yes
Type of Incident:
Self Harm
Sites Affected:
All Sites
Conclusion Summary:
Program has provided all the requested documentation. Program has addressed the incident
appropriately and no Office of Licensing violations were noted. QA has been closed.

Staffing ratios
* Start Date:
07/20/2018
* Lead Assignment:
Theresa Oram
Intake
Source:
Public/Other (e.g., complaint, news report)
Reported By:
Anonymous
Contact Info:
User Contact:
Summary of Issue:
Elevations RTC is out of legal staffing ratio majority of the time. They have excessive and abusive
physical restraints that take place. They need to have a survey conducted without notice..
Clients Involved:
Licensee Follow-Up
Office Follow-Up
Investigate Within:
Priority Due Date:
Date Priority Met:
QA Monitoring
Activity Log:
Add
Documents:
Add
Violations:
Add
Update Status
Findings
No
Sites Affected:
All Sites
Conclusion Summary:

AWOL-3 Clients
* Start Date:
11/19/2018
* Lead Assignment:
Theresa Oram
Entered By:Wendy Winder
Intake
Source:
Date of Incident:
11/15/2018
Date Reported:
11/16/2018
Reported By:
Judith Jacques
Contact Info:
User Email: jjacques@elevationsrtc.com
User Phone: 801-773-0200
Summary of Issue:
Three clients went AWOL while the group was at a chamber music concert and the U of U.
Clients Involved:

Massimiliano Frani, Brittney Thompson
Licensee Follow-Up
Staff attempted to locate the clients. Police and parents were notified. The next morning a Private
Investigator was hired to help locate the clients.
Incident is being reviewed by the leadership team to help prevent future incidents. Action steps may
include:
Modify expectations for attendance for off-campus activities that extend late into the evening (past
"quiet time in bedroom" and/or bedtime) that include limiting eligible students to Test and Impact
students (upper level) who are less likely to engage in impulsive and risky behaviors such as elopment.
-Limiting the maximum number of students to attend such events to 8.
-Modifying the student staff ratio for such events to 1:3.
-Modifying the approval and communication of attendee list for such events.
Office Follow-Up
Investigate Within:
Priority Due Date:
12/04/2018
I recommend that you verify the student to staff ratio for the activity. I also recommend you determine
if the youth involved met admission criteria for the program. Program took appropriate actions
regarding the youth that went AWOL. Lastly, see if the remaining youth at the event had required
staffing in place while the search commenced for the AWOL youth.
Date Priority Met:
QA Monitoring
Activity Log:
Add
Date Time Type Who
12/05/2018 09:25 Other Licensor Activity Theresa Oram
12/04/2018 01:47 Issued Corrective Action Plan Request (No NAA) Theresa Oram
Documents:
Add
Date Name Comment
11/19/2018 Elevations RTC Email-3 Client AWOL-11-16-18
Violations:
Add
Update Status
Findings
Yes
Type of Incident:
Runaway / AWOL
Sites Affected:
Conclusion Summary:
On the day of the outing Elevations was out of ratio. There were 11 youth with 2 staff. Elevations
indicated they would be changing this to a 1:3 ratio on outings.

Sexual Misconduct -
* Start Date:
03/28/2019
* Lead Assignment:
Theresa Oram
Entered By:Ahmed Samatar
Intake
Source:
Date of Incident:
03/20/2019
Date Reported:
03/21/2019
Reported By:
Contact Info:
User Phone:
Summary of Issue:
This is according to recollection:
indicates that he has touched or grabbed bottom several times over that last couple weeks in
line or in the group room. He tries to get close to her whenever he can.
reports that on Friday, March 15, 2019, during the skiing trip, he and were sitting on the bench
with staff. He doesn't remember if it was . The staff were talking with other peers and
reached over and grabbed crotch. He indicates it was a fast touch and there wasn't a
conversation about it.
On Saturday, March 16, 2019, on the way home with rec, was sitting on the first back seat bench and
was sitting directly behind her on the right side of the van. He states that he tapped her arm and
pointed toward her crotch. She moved his hand to be under her clothing. He reports that he digitally
penetrated her as much as he could while she was sitting. He also said that she had her hands in his
pants and that she was not rubbing, but had her hand rested on his penis.
Yesterday, March 19, 2019, and learned that they would be going to the library. said to meet
her in the adult fiction section before they left the library. He asked if they would kiss and she said yes.
HE states that when they went to the library, he first looked at movies and then went to the adult fiction
section. She said she wasn't ready yet and to come back so he came back later. They were looking for a
book for her and talking about sexual topics. They kissed each other (he says it wasn't a french kiss), and
he touched her crotch. He states that she held his arm there for about a minute.
On the way back from the library, was sitting in the front passenger seat and was sitting in the
seat right behind her. He states that he tapped her shoulder to get her attention and she didn't look, so
he tapped and rubbed her butt area for the rest of the drive trying to get her attention. She didn't ever
look back or acknowledge him on the ride.
This is according to
It has basically all happened this past week. I think about a month ago he was talking to me and he said
something about wether I was 100% bisexual or gay. That question kind of scared me. I panicked and
said I am bi and I am not. I guess it kind of gave him a green light and some leeway and I didn't realize
that I said it but I did. About a month ago we were watching Guardians of the Galaxy and and I
were on the same couch and I was sprawled out on the couch and he was sitting up for the first half and
then adjusted himself and got closer to me. 10 minutes later my hand was out and I wasn't paying
attention and he then grabbed my hand and held on to it. I didn't say anything because I didn't want
that attention. It lasted only about five minutes. That's what only happened that day and the majority
of what happened happened this week. On rec we went on a hike it was about maybe two hours to the
trail(car ride) and about two hour back. There was a kid in shotgun, don't remember who. was
sitting in the front row and is in the middle and I am by the door. was in the row behind me.
About 20-30 minutes in to the drive I turned around and said Hey that's not my seat belt, and instead of
my seatbelt around my waist it was his arm. It stayed there for about another 20 minutes and I wasn't
really doing anything because I was kind of scared. We have about 20 minutes left in the drive now and
he moved his hand from my waist down to my butt, and it was there for about 5 minutes. We are about
5 minutes away from campus and he moved his hand from my butt to my groin area. We were really
close to campus by the traffic circle going up the road and his hand then moves to my upper groin, at
this point he had his hand under my pants touching my groin and then I tapped him as I saw the school
and said that's enough. Then there was the library, same deal. We went to the library, I was in shotgun,
I was the only girl in the van and nothing happened in the van both ways. We have an hour in the library
to find a book and came up to me after about 45 minutes and then sits there and moves pretty
freaking close to me to where if there was a magazine between us it would drop. I then felt his hand go
from bracing himself up to on my hip lightly. From that point it goes from my middle half down to my
butt again, ha, but this time nothing happens with the pants, they stay where they are, but this time I
felt like a minor squeeze. Now we have about 2 minutes left (staff) comes over, he doesn't
know anything happened, moved away, I said Hi and he asked if I had the books I wanted
and then he said lets go check out. I turn and not go to the exit and go back in the isles and saw
and he told me to go back to two isles by the romance novels I think, so I am walking down the isle, ha
ha wink wink, and he is walking behind me and grabs my arm gently enough to get my attention, I
stopped and turned around and he guides my arms back and I turn and face him and before I could say
or think about anything then it happened. It starts with a K and ends with an S. It lasted about .5
seconds or less than a second and at that point I am kind of like okay I am going peace out and went and
checked out my books got in the van and came back here and tha's the end of that
Clients Involved:

,
Licensee Follow-Up
and were both placed in their rooms for 24 hours for protection and safety. Company
owner and all lead staff members were contacted. Staff who were there during the incident were
contacted to determine what they saw. Staff were trained more on looking for possible warning signs
and enforcing boundaries between peers. was called and a report made. Parents were contacted
to let them know about the incident.
and will not be allowed to talk with one another and must be at least 10 feet away from
each other at all times after this. will be sitting in the middle seat in the back or next to staff during
all drives in the future.
Office Follow-Up
Investigate Within:
Priority Due Date:
05/03/2019
Tonya Lundahl conducted the administrative staffing of this incident after reviewing all documentation
submitted. This incident is recommended to be reviewed by the licensor. Please conduct an inquiry to
assess if there is any reason to believe that rule was violated during this incident. Document any
violations noted in LION.
Date Priority Met:
QA Monitoring
Activity Log:
Add
Date Time Type Who
Documents:
Add
Date Name Comment
03/28/2019 Elevations RTC - Sexual misconduct
03/28/2019 Elevations RTC - Sexual misconduct 03-20-19 Email
Violations:
Add
Update Status
Findings
No
Sites Affected:
All Sites
Conclusion Summary:
. Finalizing investigation no critical incident occurred. Will verify supervision
at renewal tomorrow.

Suicide Attempt -
* Start Date:
05/21/2019
* Lead Assignment:
Tonya Lundahl
Intake
Source:
Date of Incident:
05/19/2019
Date Reported:
05/20/2019
Reported By:
Contact Info:
User Phone: 801-773-0200

Summary of Issue:
Student requested to use the bathroom. She was not on precautions or special interventions. Ashley
Jensen noticed that she had been in the bathroom for approximately 5 minutes so asked to do a
verbal check. When there was no response, Ashley entered the bathroom and found laying on the
floor with her hooded sweatshirt over her face. When Ashley removed the sweatshirt she saw that
had tied the hoodie string around her neck as a means to choke/asphyxiate herself. Ashley
promptly requested help and asked for 911 to be called because appeared purple. Ashley indicted
to the 911 operator that pulse was faint and breath was shallow. Ashley was instructed to begin
CPR. By the time Emergency services arrived, was conscious, breathing and able to communicate.
She was transported to Davis Hospital for assessment where no injuries were found and was released
back into the care of Elevations later that same evening.
Clients Involved:

Stephanie Martinez, Ashley Jensen, Heather Rose, Kaila Weaver, Jared Larocco
Licensee Follow-Up
Call 911. Emergency CPR delivered per instructions. returned to Elevations and was immediately
placed on precaution status for heightened supervision.
Once was found and 911 was called, communication to on-site nursing and appropriate
administrative staff (program director, on-call therapist) did not occur per policy and procedure. While
this was not a factor in preventing the incident, it made communicating with parents and others
challenging. We will be reviewing the communication flow and process and determine if any changes
are required. At a minimum, retraining on the procedure will occur in the upcoming days. Additionally, a
review of criteria to be used to place students on bathroom precautions/interventions will be done and
changes will be made if determined necessary.
Office Follow-Up
Investigate Within:
Priority Due Date:
Date Priority Met:
QA Monitoring
Activity Log:
Add
Documents:
Add
Date Name Comment
05/21/2019 Elevations RTC - Suicide attempt 05-19-19 Email
Violations:
Add
Update Status
Findings
Yes
Type of Incident:
Self Harm
Sites Affected:
All Sites
Conclusion Summary:
Licensee seems to have taken the necessary action to adhere to Office of Licensing administrative rules;
no further action required.

Client Injury-
* Start Date:
12/11/2019
* Lead Assignment:
Ahmed Samatar
Intake
Source:
Date of Incident:
12/10/2019
Date Reported:
12/11/2019
Reported By:
Eric Flores
Contact Info:
EFLORES@ELEVATIONSRTC.COM
User Phone: 8017730200
Summary of Issue:
Accidental injury:
was playing in the gym for health and fitness; he ran into another student fall backwards hitting
his head on the gymnasium floor. never lost consciousness.
Clients Involved:
Courtney Black, Mia Kreitlow, Jamie Clapier
Licensee Follow-Up
Given the force of the impact to the ground and nursing's initial assessment 911 was called to have
transported to the ER for assessment.
CT scan preformed and cleared. has a concussion and is currently on concussion protocol.
Treatment team and parents informed. will continue to be under doctor care and assessed by a
nuro specialist until medically cleared.
Office Follow-Up
Investigate Within:
Priority Due Date:
Date Priority Met:
QA Monitoring
Activity Log:
Add
Documents:
Add
Date Name Comment
12/11/2019 Elevations RTC - Client Injury 12-10-19 Email
Violations:
Add
Update Status
Findings
Yes
Type of Incident:
Any Injury - Staff/Client
Sites Affected:
All Sites
Conclusion Summary:
AWOL - Multiple clients
* Start Date:
12/18/2019
* Lead Assignment:
Ahmed Samatar
Intake
Source:
Date of Incident:
12/17/2019
Date Reported:
12/18/2019
Reported By:
Eric Flores
Contact Info:
eflores@elevationsrtc.com
Summary of Issue:
AWOL
broke out her dorm room window and she and climbed out and ran from the facility.
Russell pursued losing visual contact shortly after both students split up into the residential
neighborhood adjacent to facility.
Grave supervisor contacted the program director at 23:40 informing of the current AWOL. Calling tree
initiated; all notification went out to students' families and Elevations leadership team of current
situation.
Syracuse police department was contacted of students AWOL at 23:55. Syracuse police and program
director began searching local area and market place.
returned to campus on her own accord at 00:40. was located at local supermarket by
Syracuse police and returned to campus at 1:15.
Both students where checked back into campus per policy and procedure. Safety protocols put in place
for both students.
Clients Involved:

Eric Flores, Jennifer Morman, Russell Plummer, Jennifer Wilde
Licensee Follow-Up
Calling tree initiated
local police contacted for recovery support
Families notified / clinical professionals
Search conducted of surrounding areas and market place
Client 1 to 1 supervision / clinical team discussed safety plans and therapeutic needs moving forward for
both students.
Office Follow-Up
Investigate Within:
Priority Due Date:
Date Priority Met:
QA Monitoring
Activity Log:
Add
Documents:
Add
Date Name Comment
12/18/2019 Elevations RTC - AWOL and 12-17-19 Email
Violations:
Add
Update Status
Findings
Yes
Type of Incident:
Runaway / AWOL
Sites Affected:
All Sites
Conclusion Summary:

Assault -
* Start Date:
12/20/2019
* Lead Assignment:
Theresa Oram
Entered By:Blake Tingey
Intake
Source:
Date of Incident:
12/20/2019
Date Reported:
12/20/2019
Reported By:
Judith Jacques
Contact Info:
User Phone: 801-773-0200
Summary of Issue:
became escalated and aggressive with staff. She was placed in a restraint. During the restraint
she injured several staff members. In addition, she intentionally urinated on self and staff. After being
released from the restraint she removed clothes and began running up and down hallways. Due to
aggression and escalation, Dr Michael Connolly (Medical Director) 911 emergency services were called
to do an emergency transport to the local ED for subsequent acute psychiatric placement.
Clients Involved:

Eric Flores, Dr. Michael Connolly, Jennifer Wilde, Jennifer Montoya, Heather Rose,
Licensee Follow-Up
Injured staff members sought care at local emergency and/or instacare. Workmed contacted due to
nature of injuries. Medical director coordinating care with intake at local ED for client. Student will not
be discharged from Elevations due to escalating behaviors and inability to maintain safety.
Student will be discharged from Elevations. Elevations therapist and psychiatric provider will maintain
communication with parents. Educational Consultant, and future care providers in order to ensure
accurate historical details of behaviors and continuity of care.
Office Follow-Up
Investigate Within:
Priority Due Date:
01/08/2020
Follow up as needed.
Date Priority Met:
QA Monitoring
Activity Log:
Add
Documents:
Add
Date Name Comment
12/20/2019 Incident Report
Violations:
Add
Update Status
Findings
Yes
Type of Incident:
Abuse - Physical
Other
Serious Injury
Sites Affected:
All Sites
Conclusion Summary:
Program appears to followed procedure and taken appropriate action. No further follow up.

Sexual misconduct -
* Start Date:
12/31/2019
* Lead Assignment:
Entered By:Jeremiah Smith
Intake
Source:
Date of Incident:
12/30/2019
Date Reported:
12/31/2019
Reported By:
Contact Info:
User Phone:
Summary of Issue:
On 12/30/2019 (client) reported to that on 10/9/2019
pulled down pants in corner of their bedroom during evening free time, and started touching his
genital area and continued after he said "stop." He reported she then pulled her pants down, then back
up and began "humping" him. He reported the next day she pulled her bed covers up and exposed
herself masturbating. reported she had a sexual interaction with on her admission date which
she thought was consensual, involving both students pulling their own pants down and touching one
another's genitals.
Clients Involved:

Licensee Follow-Up
was notified on 12/30/2019. . A case was opened for the incident -
Parents were notified. Students are on physical boundary restrictions. was placed on
safety precautions for reporting thoughts of elopement and self harm/suicide. This will also help to
ensure that the 2 students do not interact. did report that no additional inappropriate activity
occurred after the incident alleged to have occurred on 10/9/2019.
Continue to monitor for self harm/suicide thoughts and maintain precaution status. Keep students
separate. Cooperate with investigating authorities in regards to requests for interviews and further
actions.
Office Follow-Up
Investigate Within:
On-site within 3 business days
Priority Due Date:
01/07/2020
Identify concerns of supervision, coordinate with CPS.
Date Priority Met:
01/09/2020
QA Monitoring
Activity Log:
Add
Date Time Type Who
02/04/2020 11:04 Other Licensor Activity Hannah Schoen
01/14/2020 11:46 Other Licensor Activity Hannah Schoen
01/09/2020 09:45 Site Visit - Unscheduled Hannah Schoen
Documents:
Add
Date Name Comment
12/31/2019 IR email
Violations:
Add
Update Status
Findings
Yes
Type of Incident:
Abuse - Sexual
Other
Sites Affected:
All Sites
Conclusion Summary:
No violations noted and case will be closed. . OL provided TA in
reporting incidents that involve a person who identifies as transgendered to note that in the report
submitted to help provide clarification.

AWOL -
* Start Date:
01/15/2020
* Lead Assignment:
Ahmed Samatar
Intake
Source:
Date of Incident:
01/10/2020
Date Reported:
01/15/2020
Reported By:
Eric Flores
Contact Info:
Summary of Issue:
broke her room window and climbed out running from facility.
Clients Involved:

Eric Flores, Sue Colgate, Matt Seelos
Licensee Follow-Up
Staff pursued losing sight; Syracuse police called to support in the search for return
to campus approximately 4 hours later by police.
Aspen is on dorm restriction for additional support and supervision.
Office Follow-Up
Investigate Within:
Priority Due Date:
Date Priority Met:
QA Monitoring
Activity Log:
Add
Documents:
Add
Date Name Comment
01/15/2020 Elevations RTC - AWOL 01-10-20 Email
01/15/2020 Elevations RTC - Notice of Violation
Violations:
Add
Violation Date Rule# Resolved Date
01/15/2020
501-1-9 General Provisions for Licensing. Investigations of Alleged Violations.
01/15/2020
Update Status
Findings
Yes
Type of Incident:
Runaway / AWOL
Sites Affected:
All Sites
Conclusion Summary:
Licensee failed to report within the required time frame and was notified of violation; no further action
required

Public complaint
* Start Date:
01/29/2020
* Lead Assignment:
Blake Tingey
Intake
Source:
Reported By:
Contact Info:
Can Contact User?: Yes
User Contact:
Summary of Issue:
Hello,
I was at Elevations RTC and I believe there is abuse and mistreatment going on. Physical
restrainst were very violent and used quite often. I have watched a kid get tackled to the ground so hard
his face was gushing blood as he was restrained there for at least half an hour. I have cleaned another
kids blood off a cinderblock wall after staff smashed his head against it. I cannot even count the number
of times I watched kids get restrained and listened to them screaming, "Stop! It hurts! Please stop!
You're hurting me!!" Kids are often restrained even when they are not a threat to themselves or anyone
else. In addition, the method of restraint is quite unsafe and results in dislocated shoulders and other
injuries. Sexual abuse is also a concern. I heard from a student who was there 12 years ago that the
, , had sex with multiple girls at the facility. I also know a kid who was
assaulted by another student and told staff. Who did nothing. Psychological abuse is also present. One
of the most egregious forms of it in my opinion was isolation. Isolation was used as a punishment, with
very minor offences getting an hour, and major ones up to 3 months. We were told that the isolation
was legal because the door was open, but the psychological effects are the same. I knew several people
who were isolated for over 2 months, and started having hallucinations because of it. There are many
many more forms of mistreatment at Elevations RTC that I do not have time to mention, but it is enough
that now I see a trauma therapist for the trauma I got there. I still have nightmares that I'm back there,
and I've been out for about a year and a half now. Elevations RTC is abusing vulnerable and suffering
teenagers and it cannot be allowed to continue. If there is anything you can do to investigate I would be
so grateful. Please let me know if there is any more information I can provide or something else I should
do. Thank you for reading my message and I hope you have sympathy for me and hundreds of other
teenagers with similar experiences.
Sincerely,
Clients Involved:
Licensee Follow-Up
NA
NA
Office Follow-Up
Investigate Within:
Priority Due Date:
02/18/2020
Identify possible client right violations as outlined in the complaint.
Date Priority Met:
02/11/2020
QA Monitoring
Activity Log:
Add
Date Time Type Who
02/11/2020 10:00 Site Visit - Unscheduled Blake Tingey
02/06/2020 09:50 Administrative Staffing Blake Tingey
Documents:
Add
Date Name Comment
01/29/2020 Elevations RTC - public complaint
Violations:
Add
Update Status
Findings
Yes
Type of Incident:
Abuse - Physical
Sites Affected:
All Sites
Conclusion Summary:
Investigator interviewed clients and staff. Unable to support any evidence of abuse, neglect, and/or
sexual misconduct. Clients feel safe and enjoy the program. Staff have no complaints about the
program and have all necessary training. No violations.

ER visit -
* Start Date:
02/19/2020
* Lead Assignment:
Amanda Johnson
Intake
Source:
Date of Incident:
02/15/2020
Date Reported:
02/19/2020
Reported By:
Cami Davis
Contact Info:
cdavis@discoversevenstars.com
Summary of Issue:
Received a call from Justin Manco, therapist, (Saturday, Feb 15th) at around 5 PM. Justin
reported that he had been on campus most of the afternoon trying to help de-escalate. Justin
reported had seemed down this morning and then escalated throughout the day. He reported
that over the past few hours, had escalated significantly, had broken the plastic ceiling light
covers, removed and broken the florescent light tubes, removed and broken the metal frame around
the light, and removed the electrical fixtures in the lights, exposing bare electrical wires. At that point,
was on the top bunk in his room with broken plastic, sharp metal frame, and glass shards all
around him in the bed. had been throwing broken glass at staff and was threatening that if
they tried to touch him, he would cut himself with broken glass or he would cut them with the broken
glass. Any time staff got near him he would brandish the broken florescent light tube and threaten to
stab them if they came any closer.
Justin and I (Gordon Day, Licensed Psychologist and Director of Seven Stars) agreed that
presented a significant threat to himself and others and since numerous attempts to de-escalate him
had failed and due to the risk for staff and other students, we would need to call the police and EMS to
have taken to the emergency department. Justin notified parents and educational consultant
of what was happening, while nursing called EMS to make arrangements for them to pick up
and take him to the North Davis Emergency Room for assessment and hopefully admittance to an acute
psychiatric facility for stabilization.
When Police and EMS were finally able to get in to the ambulance, he was transferred to North
Davis Emergency Room. Justin Manco also traveled to the Emergency Room and gave them
medications list and informed them of dangerous behaviors that afternoon. Justin reported
to me that the emergency room personnel told him he did not need to stay and that the Crisis Worker
would not be able to see until late that night. Justin left his contact information and
encouraged the team at the Emergency Room to contact him if any information was needed.
was transported from the ER to Highland Ridge for admission.
Clients Involved:

Justin Manco, Keri Douglas, Gordon Day, Sean Southard, Alexander Kelley, Nursing Staff, Syracuse Police
Department
Licensee Follow-Up
was admitted to Highland Ridge and discharged from Seven Stars. Parents notified and agreed.
Follow up with parents and other agencies involved as necessary.
Office Follow-Up
Investigate Within:
Priority Due Date:
Date Priority Met:
QA Monitoring
Activity Log:
Add
Documents:
Add
Date Name Comment
02/19/2020 Elevations RTC - Notice of Violation 02-19-20
02/19/2020 Elevations RTC - ER visit 02-15-20 Email
Violations:
Add
02/19/2020
02/19/2020
Update Status
Findings
Yes
Type of Incident:
Other
Sites Affected:
All Sites
Conclusion Summary:
The licensee seems to have taken the necessary action to adhere to the Office of Licensing
administrative rules; no further action required.

AWOL-
* Start Date:
03/09/2020
* Lead Assignment:
Entered By:Hannah Schoen
Intake
Source:
Date of Incident:
03/07/2020
Date Reported:
03/07/2020
Reported By:
Eric Flores
Contact Info:
User Email: EFLORES@ELEVATIONSRTC.COM
Summary of Issue:
During outdoor health and fitness ran when staff became distracted with who started to run
towards an out of bounds area of the field during activities. ran NE of campus and down the road.
Syracuse police where contacted for support and was located and detained by police until
Elevations staff arrived to transport back to campus.
Clients Involved:
Involved Clients:
Involved Staff: Eric Flores, Skyler Munson
Involved Witnesses:
Licensee Follow-Up
Both students placed on precautions for additional support, safety and supervision. Both students will
remain on the dorms with staff until Monday to be reevaluated by primary therapist.
Additional training and education will be offered were applicable once multidisciplinary team has
reviewed incident and debriefed with staff and students.
Office Follow-Up
Investigate Within:
Priority Due Date:
Date Priority Met:
QA Monitoring
Activity Log:
Add
Documents:
Add
Date Name Comment
Violations:
Add
Update Status
Findings
Yes
Type of Incident:
Runaway / AWOL
Sites Affected:
All Sites
Conclusion Summary:

Sexual Misconduct - Multiple Clients
* Start Date:
03/27/2020
* Lead Assignment:
Amanda Johnson
Intake
Source:
Date of Incident:
Date Reported:
03/27/2020
Reported By:
Contact Info:
User Email:
User Phone: 801-773-0200
Summary of Issue:
In a discussion regarding results of psycho-sexual testing with primary therapist and psychologist,
reported that they had engaged in sexual activity with in the bathroom. reports that
the sexual activity was consensual. However, was 13 at the time of the alleged incident.
denies any sexual activity occurred. The incident was reported to
who indicated that the case would be passed along to local law enforcement.
Clients Involved:

Anna Chauncey, Ryan Faust
Licensee Follow-Up
and are assigned bedrooms that are at opposite ends of the dorm hall. Additionally they are
on 5 foot boundary restrictions and communication restriction from each other.
Cooperation with law enforcement in regards to further investigation .
Office Follow-Up
Investigate Within:
Priority Due Date:
Date Priority Met:
QA Monitoring
Activity Log:
Add
Date Time Type Who
03/27/2020 01:22 Other Licensor Activity Blake Tingey
Documents:
Add
Date Name Comment
Violations:
Add
Update Status
Findings
Yes
Type of Incident:
Abuse - Sexual
Sites Affected:
All Sites
Conclusion Summary:
Nothing further

client injury
* Start Date:
04/14/2020
* Lead Assignment:
Amanda Johnson
Entered By:Serena Hubert
Intake
Source:
Date of Incident:
04/12/2020
Date Reported:
04/13/2020
Reported By:
Judith Jacques
Contact Info:
User Phone: 801-773-0200
Summary of Issue:
indicated to his peers that he was not feeling well. Upon standing to get a drink of water, he
fainted at which time he hit his head on the floor which is a tiled surface. The on duty nurse was called
to assess. had vomited and complained of other symptoms associated with a possible injury
(blurry vision, disoriented, headache). The on-call practitioner was consulted and ordered to be
taken to the ER for additional assessment. was transported to the ER by Elevations staff. He
returned to Elevations at approximately 1:30 AM on 4/13/2020. was not diagnosed with a
concussion. The cause of the fainting is unknown at this time.
Clients Involved:

Involved Staff: Jason Danciak, Stephanie Martinez
Involved Witnesses:
Licensee Follow-Up
Assessment by the on-duty nurse, consultation with on-call practitioner, transport to ER for additional
assessment. Nursing is following up with orders written by ER including scheduling a follow up doctor
visit within 3 days.
Nursing will continue to monitor Lincoln for symptoms of head injury. Medical appointment scheduled
as ordered by ER physician.
Office Follow-Up
Investigate Within:
Priority Due Date:
Date Priority Met:
QA Monitoring
Activity Log:
Add
Documents:
Add
Date Name Comment
04/14/2020 IR email
Violations:
Add
Update Status
Findings
Yes
Type of Incident:
Sites Affected:
All Sites
Conclusion Summary:

Medication ER
* Start Date:
04/23/2020
* Lead Assignment:
Amanda Johnson
Entered By:Robert Jones
Intake
Source:
Date of Incident:
04/22/2020
Date Reported:
04/23/2020
Reported By:
Judith Jacques
Contact Info:
User Phone: 801-773-0200
Summary of Issue:
passed a note to Ashley Jensen indicating that she had just taken a large amount of her medication.
On shift nurse, PA, medical director and poison control were consulted. was not being forthcoming
about how or what she took. was drowsy and her vitals were slightly elevated. The medical director
and PA ordered her to be transported by Elevations staff to the Layton Hospital ER for evaluation. Lab
results did not indicate the presence of high levels of medications or tylenol. However, was kept in
the ER and subsequently taken to Primary Children's Hospital on 4/23 at approximately 8:00 AM due to
elevated heart rate/blood pressure and needing assistance while standing. It is unknown and unverified
what substances has taken outside of her prescribed medication.
Clients Involved:

Courtney Black (RN), Sindi Byerly (RN), Ashley Jensen (milieu)
Licensee Follow-Up
On shift nurse and medical staff consulted in addition to poison control. Transported to local ER for
evaluation and care. Mother called. Currently we are keeping in contact with the medical providers to
gather information about what substances may have taken and how she may have gotten them. We
have reviewed our medication administration protocol which includes several steps including 2 visual
inspections by the nurse, and a mouth sweep. Nursing Director is re-educating nursing staff on protocol.
We are attempting to get information from peers as well to determine how the event may have
occurred.
When returns she will be placed on medication cheeking protocol which includes crushing the
medication when possible and putting it in applesauce or yogurt to ensure compliance.
We will continue to collect information on the event and review policies and procedures for additional
measures or appropriate revisions as necessary.
Office Follow-Up
Investigate Within:
Priority Due Date:
05/08/2020
Date Priority Met:
QA Monitoring
Activity Log:
Add
Documents:
Add
Date Name Comment
04/23/2020 IR email
Violations:
Add
Update Status
Findings
Yes
Type of Incident:
Alcohol / Substances
Sites Affected:
All Sites
Conclusion Summary:
I sent an email to Elevations asking for further informationJudith Jacques
Fri, May 1, 10:29 AM (6 days ago)
to me
Hi Amanda-
was transferred from Primary Children's hospital to Uni on 4/24/20. The decision was made by all
involved (mom, treatment team here, Primary Children's) that she needed a higher level of psychiatric
care. Thus, she is currently discharged from Elevations. The plan is that she will return to Elevations once
she has attained a higher level of psychiatric stabilization. This is likely to be up to another 6 weeks as
they are considering ECT for her. has articulated that she wants to return to Elevations. However,
she has not been communicative about if and how she was able to cheek the medications she originally
claimed she did. We have asked the peers in her group and have not been able to gain any additional
information that may help us to ascertain how she may have been able to cheek the medications. In the
absence of further details we have done additional staff education on the current medication
administration policy to ensure compliance and we did complete room searches for contraband. No
contraband was discovered.
When does return she will be on the additional medication cheeking protocol as mentioned.
Let me know if you need anything further. Thank you!. The following email was sent and is no
longer in their program.

AWOL -
* Start Date:
05/11/2020
* Lead Assignment:
Amanda Johnson
Entered By:Jeremiah Smith
Intake
Source:
Date of Incident:
05/09/2020
Date Reported:
05/11/2020
Reported By:
Judith Jacques
Contact Info:
User Phone: 801-773-0200
Summary of Issue:
was on a rock climbing outing with a group of peers and staff members. There were 6 students and
3 staff members present. ran away from the group at 14:30. Staff member, Kyle Bodkin witnessed
him leaving and ran after him but lost sight of him shortly thereafter. The county sheriff's office was
contacted who immediately sent a dispatch to local law enforcement and began searching along with
the other staff members present. A member of the sheriff's office found him hiding in a outdoor
restroom at approximately 15:45 and returned him to the group. was compliant and returned to
Elevations without further incident.
Clients Involved:

Kevin Uncapher, Regina Kessler, Kyle Bodkin (Staff)
- all residents on the outing
Licensee Follow-Up
Staff members searched and contacted local law enforcement agencies for support. Facility leaders
were contacted as well to aide in providing relevant information. returned to Elevations without
incident and was assessed by on-site nursing staff. had several cuts and scratches that were
treated by the nurse on-site. has been placed on safety precautions.
The incident was reviewed for actions taken as well as decision to allow to go on the outing.
Additionally, was interviewed to assess his state of mind as well as the event. indicated that
he had not been planning to run and acted impulsively. had been on a high leadership level for
several weeks. The decision to allow him to go off campus was made collaboratively among the entire
treatment team. There were no indicators that was at risk for this behavior. Ratios during the
outing were adequate (3 staff, 6 students) and staff acted swiftly.
Office Follow-Up
Investigate Within:
Priority Due Date:
Date Priority Met:
QA Monitoring
Activity Log:
Add
Documents:
Add
Date Name Comment
05/11/2020 Licensor Notification
05/11/2020 IR email
Violations:
Add
Update Status
Findings
Yes
Type of Incident:
Runaway / AWOL
Sites Affected:
All Sites
Conclusion Summary:

AWOL - Multiple Clients
* Start Date:
06/15/2020
* Lead Assignment:
Intake
Source:
Date of Incident:
06/13/2020
Date Reported:
06/15/2020
Reported By:
Eric Flores
Contact Info:
Summary of Issue:
During transition from the cafeteria back to the dorms; the 4 students AWOL heading West of campus.
Staff immediately pursued all the students apprehending than followed by and
Students where all returned to campus without further incident.
Clients Involved:
Involved Clients:
Involved Staff: Jason Danciak, Issac Gonzales, Braxton Boatright, Rhett Bingham
Involved Witnesses:
Licensee Follow-Up
Students placed on dorm restrictions and additional supervision provided throughout the weekend for
support and safety.
The multidisciplinary team is review and discussing this incident. Additional support and training will be
provided should the team determine the needs.
Office Follow-Up
Investigate Within:
Priority Due Date:
Date Priority Met:
QA Monitoring
Activity Log:
Add
Documents:
Add
Date Name Comment
Violations:
Add
Update Status
Findings
Yes
Type of Incident:
Runaway / AWOL
Sites Affected:
All Sites
Conclusion Summary:

AWOL - Multiple Students
* Start Date:
06/15/2020
* Lead Assignment:
Intake
Source:
Date of Incident:
06/13/2020
Date Reported:
06/15/2020
Reported By:
Eric Flores
Contact Info:
Summary of Issue:
During transition from the cafeteria back to the dorms; the 4 students AWOL heading West of campus.
Staff immediately pursued all the students apprehending than followed by and
Students where all returned to campus without further incident.
Clients Involved:
Involved Clients:
Involved Witnesses:
Involved Staff: Jason Danciak, Issac Gonzales, Braxton Boatright, Rhett Bingham
Licensee Follow-Up
Students placed on dorm restrictions and additional supervision provided throughout the weekend for
support and safety.
The multidisciplinary team is review and discussing this incident. Additional support and training will be
provided should the team determine the needs.
Office Follow-Up
Investigate Within:
Priority Due Date:
Date Priority Met:
QA Monitoring
Activity Log:
Add
Documents:
Add
Date Name Comment
Violations:
Add
Update Status
Findings
Yes
Type of Incident:
Runaway / AWOL
Sites Affected:
All Sites
Conclusion Summary:

AWOL - Multiple Clients
* Start Date:
06/16/2020
* Lead Assignment:
Intake
Source:
Date of Incident:
06/13/2020
Date Reported:
06/15/2020
Reported By:
Eric Flores
Contact Info:
Summary of Issue:
Students went AWOL during team transition form the cafeteria back to the dorms.
Clients Involved:
Involved Clients:
Involved Staff: Issac Gonzales, Jason Danciak, Rhett Bingham
Licensee Follow-Up
Staff immediately pursued students apprehending all four students shortly after they run. All students
returned with staff safely back to campus without further incident.
Multidisciplinary team is reviewing this incident to determine if there is an areas for improvement or
training.
Office Follow-Up
Investigate Within:
Priority Due Date:
Date Priority Met:
QA Monitoring
Activity Log:
Add
Documents:
Add
Date Name Comment
Violations:
Add
Update Status
Findings
Yes
Type of Incident:
Runaway / AWOL
Sites Affected:
All Sites
Conclusion Summary:
no further actio

COVID 19 - Staff
* Start Date:
07/06/2020
* Lead Assignment:
Theresa Oram
Intake
Source:
Date of Incident:
07/04/2020
Date Reported:
07/05/2020
Reported By:
Judith Jaques
Contact Info:
User Email: jjacques@Hotmail.com
User Phone: 801-773-0200
Summary of Issue:
Taylor Smith, RN was contacted by the local health department as the nurse on shift. She was told that
(grave shift staff) had tested positive for COVID-19. Nursing department worked with
the health department to submit a list of clients and staff who were at risk of exposure. At this time, it
was determined by the health department that no staff or clients needed to be tested or quarantined
for the following reasons: had not worked since June 29th. had worked with 2-3 other
staff members when she was potentially contagious but maintained a minimum of 6 feet distance at all
times. did not have contact with any clients during that time. Daily symptom and temperature
checks indicate to symptomatic clients or staff to date.
Clients Involved:
NA
Licensee Follow-Up
Checked temperature, symptom and work logs. Communicated to co-workers about minimal risk of
exposure. Education provided about not working with symptoms. Worked with health department to
identify risk level and folks involved.
Continue with COVID-19 risk management and prevention plan. Checking for symptoms and
temperatures on-going. Working with our medical staff to identify risks and actions needed.
Office Follow-Up
Investigate Within:
Priority Due Date:
07/10/2020
Follow up using OL COVID protocol.
Date Priority Met:
07/09/2020
QA Monitoring
Activity Log:
Add
Date Time Type Who
Documents:
Add
Date Name Comment
08/04/2020 Infectious Disease Policy 2020
08/04/2020 COVID Policy 2020
Violations:
Add
Update Status
Findings
Yes
Type of Incident:
Illness Outbreak
Sites Affected:
All Sites
Conclusion Summary:

Client Altercation
* Start Date:
07/27/2020
* Lead Assignment:
Amanda Johnson
Intake
Source:
Date of Incident:
07/25/2020
Date Reported:
07/27/2020
Reported By:
Eric Flores
Contact Info:
Summary of Issue:
and were involved in a brief altercation. According to reports by hit her 3 times on
the mouth. On-site nursing staff assessed for injuries. No injuries, swelling, redness, or marks were
noted and indicated that she was "fine" to the nurse. Subsequently, father reported to the
local Syracuse Police Department that his daughter was assaulted and requested a wellness check. The
police conducted a wellness check on 7/26.
Clients Involved:
and
Involved Staff: Eric Flores, Quiani Baker, Stephanie Martinez-Gil, Katie Flitton
Involved Witnesses:
Licensee Follow-Up
Students separated and the multidisciplinary team review incident. The primary therapist will contact
dad after the this incident has been thoroughly reviewed.
Multidisciplinary team is assessing student for appropriateness of placement although this student does
not have a history of assaultive behaviors. Continued separation of students providing additional
supervision, support, and safety.
Office Follow-Up
Investigate Within:
Priority Due Date:
Date Priority Met:
QA Monitoring
Activity Log:
Add
Documents:
Add
Date Name Comment
Violations:
Add
Update Status
Findings
No
Sites Affected:
Conclusion Summary:
Client is ok with no major harm

COVID-19 Staff 8/11
* Start Date:
08/06/2020
* Lead Assignment:
John Ortiz
Intake
Source:
Date of Incident:
Date Reported:
08/06/2020
Reported By:
Contact Info:
Summary of Issue:
1 confirmed staff with COVID-19.
Clients Involved:
none
Licensee Follow-Up
mask wearing, social distancing, temperature and symptom monitoring/recording of students and staff,
staff training, additional cleaning and hygiene measures
not at this time, health department determined all clients and staff with possible exposure were at low
risk due to mask wearing, social distancing, and timing of symptoms - additional monitoring of
symptoms for those clients and staff is being conducted
Office Follow-Up
Investigate Within:
Priority Due Date:
08/19/2020
Communicated to licensee - Thank you for providing the Office of Licensing with your COVID Incident
Report information. The last time we received an update was on 8/6/2020. Please fill out this form with
your most recent update.
Thank you for taking the time to complete this.
Office of Licensing
Date Priority Met:
08/11/2020
QA Monitoring
Activity Log:
Add
Date Time Type Who
08/17/2020 12:53 Other Licensee Contact John Ortiz
08/11/2020 11:09 Other Licensee Contact John Ortiz
Documents:
Add
Date Name Comment
08/12/2020 COVID Update delete
08/10/2020 Elevations RTC - COVID staff email
08/06/2020 Elevations RTC - COVID Incident Report
Violations:
Add
Update Status
Findings
Yes
Type of Incident:
Illness Outbreak
Sites Affected:
All Sites
Conclusion Summary:
Licensee reports - no - no staff or clients met the criteria for requiring isolation or quarantine.

Complaint - Abuse
* Start Date:
08/18/2020
* Lead Assignment:
Blake Tingey
Entered By:Theresa Oram
Intake
Source:
Reported By:
Contact Info:
Summary of Issue:
The practices at Elevations RTC are abusive to the point where multiple kids attempt suicide each month
just to get out of there. Many abusive disciplinary practices are employed to brainwash (not
metaphorically, these are techniques used in organized abuse) kids into blindly obedient robots under
the guise of "treatment." Also, they purposefully overmedicate and the therapists blatantly overstate
their qualifications, often retraumatizing people and rarely, if ever, practicing ethical therapy.
Clients Involved:
Unknown
Unknown
Licensee Follow-Up
NA
NA
Office Follow-Up
Investigate Within:
Priority Due Date:
08/25/2020
Identify concerns addressed in the complaint, identify possible reporting concerns and overall safety of
the facility.
Date Priority Met:
08/24/2020
QA Monitoring
Activity Log:
Add
Date Time Type Who
09/10/2020 02:00 Site Visit - Scheduled Blake Tingey
08/27/2020 01:30 Site Visit - Scheduled Blake Tingey
08/25/2020 10:49 Collateral Contacts Blake Tingey
Documents:
Add
Date Name Comment
09/15/2020 Investigation Notes Notes by Blake Tingey
09/11/2020 Clinical Note 8/12/2020 clinical note.
09/03/2020 Incident Report from October 2019.
09/03/2020 Documents Critical Incidents for multiple clients and email of training for staff
comments.
08/25/2020 Client List As of 8/21/2020.
08/18/2020 Complaint Email
Violations:
Add
Update Status
Findings
Yes
Type of Incident:
Self Harm
Serious Injury
Sites Affected:
All Sites
Conclusion Summary:
Investigators never heard from original complainant to get more specifics or details of the allegations.
Investigators randomly interviewed several clients and staff and found little to no concerns. A few
incidents were mentioned in the interviews that the investigators followed up on and it seems the
program responded appropriately to those incidents. An incident of self harm was not reported, but no
injuries were sustained according to the reports.

Restraint Injury -
* Start Date:
09/21/2020
* Lead Assignment:
Ahmed Samatar
Intake
Source:
Date of Incident:
09/18/2020
Date Reported:
09/21/2020
Reported By:
Contact Info:
User Email:
User Phone:
Summary of Issue:
Staff attempted to place student in a restraint during which the student and staff's heads collided and
again bumping both their heads when falling to the ground. Student was sent out to be assessed at the
ED and staff later was sent out to be assessed as well. Student currently on concussion protocol and
staff on home rest.
Clients Involved:
Involved Clients:
Involved Witnesses:
Involved Staff:
Licensee Follow-Up
Staff on unpaid administrative level as this incident is under investigation.
Pending investigation.
Office Follow-Up
Investigate Within:
Priority Due Date:
09/28/2020
Identify possible client rights violations, identify concerns of physical intervention techniques.
Date Priority Met:
09/28/2020
QA Monitoring
Activity Log:
Add
Date Time Type Who
10/01/2020 01:50 Collateral Contacts Ahmed Samatar
Documents:
Add
Date Name Comment
11/16/2020 Elevations RTC - Notice of Violation (staff )
10/19/2020 Elevations RTC - Staff's First Aid card
10/19/2020 Elevations RTC - Staff's CPR card
10/19/2020 Elevations RTC - Staff's PCS Certificate
10/08/2020 Elevations RTC - follow up and response email
09/21/2020 Incident Report delete
Violations:
Add
11/16/2020
501-2-8 Core Rules. Rights of Consumers.
11/16/2020
Update Status
Findings
Yes
Type of Incident:
Sites Affected:
All Sites
Conclusion Summary:
The staff was terminated and the client was discharged back to his home state of . I called
to report the alleged Physical Abuse. However, no new updates. I sent the program the violation and let
them know that I would follow up if new updates come from

ER visit
* Start Date:
10/15/2020
* Lead Assignment:
Robert Jones
Entered By:Robert Jones
Intake
Source:
Date of Incident:
10/14/2020
Date Reported:
10/15/2020
Reported By:
Judith Jacques
Contact Info:
Summary of Issue:
At approximately 1:30 pm on 1/14/2020, reported to nursing staff on shift that she was having
difficulty breathing and unexplained pain in his legs. The use of prescribed inhaler did not help with
symptoms. The Medical Director ordered her to be examined at local Emergency Room. was
transported by Elevations staff to Layton IHC and examined. She was diagnosed with pneumonia and a
lung mass. returned to Elevations the same evening. is taking prescribed medications and will be
taken to have lung mass biopsied as ordered by ER physician.
Clients Involved:

Courtney Black, Dr. Michael Connolly
Licensee Follow-Up
was taken to Layton IHC for assessment by Elevations staff and subsequently returned the same
evening with a diagnosis of pneumonia and lung mass. is being monitored by on shift nursing staff
and PA. has started taking prescribed medication.
will be scheduled for a biopsy for the lung mass as ordered by the ER physician. Medical staff on site
will monitor during recovery and ensure all medical orders are followed.
Office Follow-Up
Investigate Within:
Priority Due Date:
Date Priority Met:
QA Monitoring
Activity Log:
Add
Documents:
Add
Date Name Comment
10/15/2020 IR email
Violations:
Add
Update Status
Findings
Yes
Type of Incident:
Other
Sites Affected:
All Sites
Conclusion Summary:
Self Harm -
* Start Date:
10/19/2020
* Lead Assignment:
Intake
Source:
Date of Incident:
10/16/2020
Date Reported:
10/19/2020
Reported By:
Judith Jacques
Contact Info:
Summary of Issue:
reported self-harming on his upper right thigh using a large staple that was removed from a piece
of furniture. Upon assessment by nursing staff and consultation with the on-call medical provider,
was transported to the Emergency Room at Layton IHC to assess if stitches were required. received
5 stitches as returned that evening to Elevations.
Clients Involved:

Involved Staff: Sindi Byerly, Cherish Crawfor
Licensee Follow-Up
On site nursing staff called for assessment of injury. On-call medical provider contacted for consultation.
Transported to ER to assess need for stitches. was placed on safety precautions for line of sight
supervision.
will be on safety precautions supervision protocol until order discontinued by LIP. Nursing will
monitor wound area for signs and symptoms of infection. Medical orders from ER physician will be
followed.
Office Follow-Up
Investigate Within:
Priority Due Date:
Date Priority Met:
QA Monitoring
Activity Log:
Add
Documents:
Add
Date Name Comment
Violations:
Add
Update Status
Findings
Yes
Type of Incident:
Sites Affected:
All Sites
Conclusion Summary:

Client Injury/Self Harm -
* Start Date:
10/30/2020
* Lead Assignment:
Amanda Johnson
Intake
Source:
Date of Incident:
10/30/2020
Date Reported:
10/30/2020
Reported By:
Judith Jaques
Contact Info:
Summary of Issue:
self harmed on his upper right thigh while in the shower. He used a paper staple to pick open an
old self-harm wound which had scarred over. Upon assessment, the on-shift RN and PA decided to have
transported to the local Instacare to be evaluated for the need for stitches. received stitches
for the wound.
Clients Involved:

Heather Rose, Cynthia Byerly
Licensee Follow-Up
Injury was reported to on-shift RN who consulted with PA. Transported to Instacare and received
stitches. Nursing staff will monitor wound for care and follow all medical orders received from attending
medical provider. No additional follow up is required at this time with Instacare.
has been placed on safety precautions with heightened supervision. A staff member will supervise
shower and bathroom time directly outside of the immediate enclosure. Checking pockets for
contraband prior to using the bathroom facilities.
Office Follow-Up
Investigate Within:
Priority Due Date:
Date Priority Met:
QA Monitoring
Activity Log:
Add
Documents:
Add
Date Name Comment
Violations:
Add
Update Status
Findings
Yes
Type of Incident:
Self Harm
Serious Injury
Sites Affected:
All Sites
Conclusion Summary:

Self Harm -
* Start Date:
11/23/2020
* Lead Assignment:
Intake
Source:
Date of Incident:
11/20/2020
Date Reported:
11/23/2020
Reported By:
Eric Flores
Contact Info:
User Email: eflores@elevationsrtc.com
Summary of Issue:
self-harmed when in the shower with an earing on his upper thigh. After nursing assessed the injury
a transport team was assembled to transport to the ER for assessment. received 6 stiches and
was released returning to Elevations without further incident.
Clients Involved:
Involved Staff: Brandy Bronson, Jason Danciak, Kyle Bodkin, Brandon Charlton
Licensee Follow-Up
Transport to ER for additional assessment. Student returned to campus without further incident.
Student's jewelry and any other potential items that could be used to self-harm with taken until the
multidisciplinary team can review the incident and define safety plan moving forward.
Office Follow-Up
Investigate Within:
Priority Due Date:
Date Priority Met:
QA Monitoring
Activity Log:
Add
Documents:
Add
Date Name Comment
Violations:
Add
Update Status
Findings
Yes
Type of Incident:
Self Harm
Sites Affected:
All Sites
Conclusion Summary:

Contraband (medication)
* Start Date:
12/02/2020
* Lead Assignment:
Travis Broderick
Intake
Source:
Date of Incident:
12/01/2020
Date Reported:
12/02/2020
Reported By:
Eric Flores
Contact Info:
Summary of Issue:
returned to campus from a holiday home visit on 11/30/20. went through check in
procedures upon returning to campus. On 12/01/20 approximately 21:30 approached staff with
a concern that he had heard had handed out a controlled substance to a few peers that he had
smuggled on campus from his home visit. When staff investigated the concern further and interviewed
it was found that had snuck in two little baggies with 10mg in each bag of DMT powder
(dimethyltryptamine) that was hidden underneath his binder during the check in procedure on
11/30/20.
also indicated that he shared the powder with two peers; . Both
students questioned and admitted to getting the DMT powder from and ingesting the powder
approximately 11:30am on 12/01/20.
Clients Involved:

Eric Flores, Stephanie Martinez, Jaryd Mattson, & Stanley Taufa
Licensee Follow-Up
Medical team assessed all 3 students. Room searches and precautions ordered; a change of clothes
performed. No additional contraband was found.
All students' parents contacted as well as local law enforcement for the controlled substance.
Office Follow-Up
Investigate Within:
Priority Due Date:
Secondary Assignment:Ad-hoc licensorAhmed SamatarAlan HolbrookAmanda JohnsonBackground
Screener 1Barry AssayBlake TingeyBrenda MartinezBuu DiepCarlie TorresChanhda Ousa-
KhommarathChris WnekCindy LundDAAS AssociatedDHS / DCFSDSPD CertifiedDavid DingerDustin
PenmanElizabeth HoffmannEllen CarleGayle LucianoGreg HirstHailey FeichkoJanice WeinmanJeff
HarrisJenilee DavidsonJennifer BussJennifer HintonJim JenningsJohn OrtizJolene Dalley-WatersKacee
ArringtonKelly AndersonKolyn TacyLaura RoeLauren AndrewsLexi FrustaciLisa D. CarterMargaret
StrasburgMelinda ThompsonMichelle PiersonNathan PonisNathan CruzNichol TidwellNicole
LaubRachael StuartRebecca MonsenRobert JonesRusty HendricksonSerena HubertShae RaganStephanie
RobbTeresa JonesTheresa OramTonya LundahlTravis Broderick
Date Priority Met:
QA Monitoring
Activity Log:
Add
Documents:
Add
Date Name Comment
12/02/2020 Elevations RTC - Unauthorized substances 12-01-20 Email
Violations:
Add
Update Status
Findings
Yes
Type of Incident:
Alcohol / Substances
Sites Affected:
All Sites
Conclusion Summary:
Licensee seems to have taken the necessary action to adhere to Office of Licensing

Self Harm -
* Start Date:
12/29/2020
* Lead Assignment:
Ahmed Samatar
Intake
Source:
Date of Incident:
12/18/2020
Date Reported:
12/29/2020
Reported By:
Eric Flores
Contact Info:
8016987720
Summary of Issue:
reported to staff that he self-harmed while in the shower with a small metal piece that they had
found outside on the ground. handed the contraband to staff and nursing was called to assess
injury.
Clients Involved:

Jason Danciak, Erin Harris, Cynthia Byerly
Licensee Follow-Up
Nursing assessed and cleared the area. It was determined that should be sent out for additional
assessment. was taken to Urgent Care and received 4 stitches in his upper right thigh.
returned to campus without further incident.
Room search was conducted on and he was placed on precautions for additional support, safety
and supervision. Student will do a pocket check and staff will search all items before and after shower
times.
Office Follow-Up
Investigate Within:
Priority Due Date:
01/04/2021
Identify safety concerns, conduct investigation with other opened investigations.
Date Priority Met:
01/04/2021
QA Monitoring
Activity Log:
Add
Date Time Type Who
Documents:
Add
Date Name Comment
12/29/2020 Incident Email
Violations:
Add
12/29/2020
02/01/2021
Update Status
Findings
Yes
Type of Incident:
Sites Affected:
All Sites
Conclusion Summary:
The program took the appropriate action to attend to the medical needs of the client during my
interview with other clients no other safety concerns were noted. Licensee failed to report within the
required time frame and was notified of the violation; no further action required.

Alleged Abuse
* Start Date:
01/05/2021
* Lead Assignment:
Blake Tingey
Intake
Source:
Other Regulatory Agency (e.g., DCFS, JJS, Law Enforcement)
Reported By:
,
Contact Info:
Summary of Issue:
It is reported that the child has said that there is an increase in traumatic experiences at the facility and
have been there for over a year and there is more trauma. No further details are known beyond this.
It is reported that there have been concerns for forced medicating, not being able to see their parents,
physical, sexual, and emotional abuse of the children at the facility. It is reported that there are concerns
for sexual relationships with staff, improper restraints and slamming children into the ground or walls,
and excessive confinement. It is reported that there are interventions that are not evidence based. It is
reported
that there are concerns that licensing is a self governed organization and they allow this behavior to
happen in facilities like this. It is reported that there are concerns of mail being read, phone calls being
monitored.
It is believed that there is supposed to be a box where children can voice their concerns at residential
treatment facilities that are locked and facility staff cannot read this and there are concerns that
children don't have a way to voice their concerns without staff being aware of this and ignoring them.
It is reported that there are concerns about children staying in residential treatment for too long and it
affects their mental health. It is reported that this is concerning because adults would need severe
mental health concerns to be inpatient for a year.
Clients Involved:
No further details are known about this
child.
Unknown
Licensee Follow-Up
NA
NA
Office Follow-Up
Investigate Within:
Priority Due Date:
01/12/2021
Identify concerns addressed in the complaint, specifically, possible client rights and behavior
management concerns.
Date Priority Met:
01/07/2021
QA Monitoring
Activity Log:
Add
Date Time Type Who
01/07/2021 10:15 Interview(s) Blake Tingey
Documents:
Add
Date Name Comment
03/05/2021 Program response Executive Clinical Directors email terminating Internal and Team
Focus (IF TF) process.
01/05/2021 LE Report
01/05/2021 Incident Email
Violations:
Add
Update Status
Findings
No
Sites Affected:
All Sites
Conclusion Summary:
Coordinated this investigation with another investigator, Ahmed Samatar. We conducted client
interviews together to determine if there was any abuse or neglect happening at the program. The
interviews resulted in a few concerns that Ahmed followed up on. Ahmed was unable to substantiate
any allegations and believes the program is responding appropriately to clients needs. No further
action.

AWOL -
* Start Date:
01/08/2021
* Lead Assignment:
Amanda Johnson
Intake
Source:
Date of Incident:
01/06/2021
Date Reported:
01/07/2021
Reported By:
Eric Flores
Contact Info:
User Email: eflores@elevationsrtc.com
Summary of Issue:
During the team's transition back to the dorm from the cafeteria, ran.
Clients Involved:

Jason Danciak, Amberlyn Coulson, Stephanie Martinez-Gil
Licensee Follow-Up
Staff immediately pursued as she ran East from campus. ran approximately a quarter mile
before staff apprehended her. Staff detained as supporting staff arrived with a transport vehicle.
was escorted back to campus without further incident.
was placed on precautions and dorm restriction for additional supervision, safety and support.
Office Follow-Up
Investigate Within:
Priority Due Date:
Date Priority Met:
QA Monitoring
Activity Log:
Add
Documents:
Add
Date Name Comment
Violations:
Add
Update Status
Findings
Yes
Type of Incident:
Runaway / AWOL
Sites Affected:
All Sites
Conclusion Summary:

Medical emergency -
* Start Date:
01/12/2021
* Lead Assignment:
Ahmed Samatar
Intake
Source:
Date of Incident:
01/10/2021
Date Reported:
01/11/2021
Reported By:
Judith Jacques
Contact Info:
Summary of Issue:
On-site nursing staff was notified at 1150 that was doing a word search when their eyes rolled in the
back of their head for 3 seconds. was tired, cold, and had a headache after the incident. Upon
assessment vitals WNL with a slightly elevated BP, PERRLA, Bilateral grips strong and equal was A&O
X3 but was slow at giving responses, hands were cold to the touch as well as clammy and the
marks from the blood pressure marks stayed on arm for 15 minutes. Nursing contacted
physician and nursing was advised to do a rapid COVID test and monitor for an additional 30 minutes
after the negative result. was brought out into the hallway on their mattress so they could be
properly monitored by staff. The COVID test was read after 15 minutes and the results were negative.
Another set of vitals were taken and were WNL other than an Elevated blood pressure. Physician
notified of the results and still having the neurological effects. A VO was given to nursing to send
out to the Emergency room to be further evaluated. mother was contacted at 1315 to notify of the
incident and consent was given to nursing to send out. mother also had nursing
notify the ER that had seizures when they were younger but grew out of them, Nursing sent staff
with a sticky note of that information as well as number so he ER could give her updates.
left Elevations at 1320 with staff.
Clients Involved:

Taylor Smith RN, Stanley Taufa (staff)
Licensee Follow-Up
On-site nursing contacted physician and nursing was advised to do a rapid COVID test and monitor
for an additional 30 minutes after the negative result. remained under continuous observation and
supervision. The COVID test was read after 15 minutes and the results were negative. Another set of
vitals were taken and were WNL other than an elevated blood pressure. Physician notified of the results
and still having the neurological effects. A verbal order was given to nursing to send out to the
emergency room to be further evaluated. mother was contacted at 13:15 to notify of the incident
and consent was given to nursing to send out. mother indicated that had seizures as a small
child but had no recent history of them. left Elevations at 1320 with staff.
returned to Elevations at approximately 17:30. The emergency room physician indicated that the
event was a "neurological abnormality" and was referred to see a seizure specialist. Elevations nursing is
working with that referred physician's office to schedule an appointment as soon as possible.
Office Follow-Up
Investigate Within:
Priority Due Date:
Date Priority Met:
QA Monitoring
Activity Log:
Add
Documents:
Add
Date Name Comment
01/12/2021 Elevations RTC - Medical emergency 01-10-21 Email
Violations:
Add
Update Status
Findings
Yes
Type of Incident:
Other
Sites Affected:
All Sites
Conclusion Summary:

ER visit -
* Start Date:
01/25/2021
* Lead Assignment:
Travis Broderick
Intake
Source:
Date of Incident:
01/23/2021
Date Reported:
01/25/2021
Reported By:
Eric Flores
Contact Info:
Summary of Issue:
removed a triple "A" battery form a peer's pair of headphone and swallowed it. It is unclear as to
as why choose to swallow the battery. immediately came to staff in tears informing staff to
what she had done. did comment on wanting to be sent out. has a history of AWOL.
Clients Involved:

Rhett Bingham, Kaylee Gubler, Savannah Barraza
Licensee Follow-Up
Nursing immediately contacted by staff to assess Medical provider "on-call" contacted as was
parents after nursing assessment. Order was given to transport to ER for further assessment.
Transport team assembled and was transport to ER. X-ray done and ER doc stated the battery was
intact and should pass in a day or two. ER doc gave directions to bring back if she started to have
any pain or battery did not pass in 3 days. returned to campus without further incident.
under close medical supervision until battery passes. is on precautions for additional
supervision, safety, and support.
Office Follow-Up
Investigate Within:
Priority Due Date:
Date Priority Met:
QA Monitoring
Activity Log:
Add
Documents:
Add
Date Name Comment
01/25/2021 Elevations RTC - ER visit 01-23-21 Email
Violations:
Add
Update Status
Findings
Yes
Type of Incident:
Self Harm
Sites Affected:
All Sites
Conclusion Summary:
Licensee seems to have taken the necessary action to adhere to Office of Licensing

Self harm -
* Start Date:
01/31/2021
* Lead Assignment:
Ahmed Samatar
Intake
Source:
Date of Incident:
01/30/2021
Date Reported:
01/31/2021
Reported By:
Eric Flores
Contact Info:
Summary of Issue:
used a broken colored pencil to self-harm with. Staff walked into her room during routine
visual checks and found sitting in the corner of her room scratching at her wrist with the
broken pencil.
Clients Involved:

Caron Cordes, Jason Danciak, Braxton Boatright
Licensee Follow-Up
Staff asked for the broken pencil and gave it to staff without incident. Staff immediately
contacted nursing to assess injury. During assessment claimed she had also
swallowed pieces of the broken pencil.
On-call provider and parents contacted. Order and consent given to send to ER for further
assessment. Transport team assembled and was transported to Layton Hospital ER.
received 4 sutures on her L-wrist. Follow-up in 8 days to remove sutures. X-ray did not show
any foreign objects in stomach. Instructions were to bring back to ER if she started
to have adnominal pains. returned to campus @ 22:20 without further incident.
Room search conducted for additional contraband. placed on precautions for additional
supervision, safety, and support.
Office Follow-Up
Investigate Within:
Priority Due Date:
Date Priority Met:
QA Monitoring
Activity Log:
Add
Documents:
Add
Date Name Comment
01/31/2021 Elevations RTC - ER visit self harm 01-30-21 Email
Violations:
Add
Update Status
Findings
Yes
Type of Incident:
Self Harm
Sites Affected:
All Sites
Conclusion Summary:

Self Harm - Transport to ER
* Start Date:
02/10/2021
* Lead Assignment:
Nicole Laub
Entered By:Nicole Laub
Intake
Source:
Date of Incident:
02/09/2021
Date Reported:
02/10/2021
Reported By:
Eric Flores
Contact Info:
Summary of Issue:
self reported after using the bathroom that he used a broken piece of plastic in the bathroom to self-
harm with. was unclear what the plastic piece was from and only that he found it on the ground>
also stated he flushed it after using it to self-harm with.
Clients Involved:

Jordan Willis, Cynthia Byerly
Licensee Follow-Up
Staff asked if there was any other broken pieces; stated no. Staff immediately walked to the
nursing station for assessment.
On-call provider and parents contacted. Order and consent given to send to ER for further
assessment. Transport team assembled and was transported to Layton Hospital ER.
received 7 running stitches on his L-forearm. Follow-up in 7 days to remove stitches.
returned to campus without further incident.
Room search conducted for additional contraband. placed on precautions for additional supervision,
safety, and support.
Office Follow-Up
Investigate Within:
Priority Due Date:
Date Priority Met:
QA Monitoring
Activity Log:
Add
Documents:
Add
Date Name Comment
02/10/2021 HSLIC Incident Report Form - Elevations
Violations:
Add
Update Status
Findings
Yes
Type of Incident:
Other
Self Harm
Serious Injury
Sites Affected:
All Sites
Conclusion Summary:
Licensee seems to have
taken the necessary action to adhere to Office of Licensing administrative rules; no further action
required."

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Elevations RTC

2650 West 2700 South, Syracuse, UT 84075 (Davis County)

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