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The staff of the Black Hills Children’s Home should have called 911 immediately rather than waiting one hour and 41 minutes after a girl ran away from the facility, according to reports from two regulatory agencies.

The reports also say, among other things, that the facility lacked a sufficient emergency preparedness plan, failed to conduct training or drills for runaways, fell into complacency after previous attempted runaways, conducted an initially disorganized search for the runaway girl, used several different radio communication channels during the initial search instead of one common channel, and did not follow the organization’s own policy regarding lost children on campus.

Nine-year-old Serenity Dennard ran away on foot from the Black Hills Children’s Home on Feb. 3 and still has not been found, despite an extensive investigation and exhaustive searches of the rocky and forested area around the home, which is between Keystone and Rockerville. The day of the runaway, low temperatures in the area were around zero degrees.

Since the runaway, the state Department of Health has conducted a survey of the Children’s Home on behalf of the federal Centers for Medicare and Medicaid Services (CMS). Much of the funding for the Children’s Home comes from Medicaid, a health-care insurance program for low-income people that combines state and federal dollars.

The state Department of Social Services (DSS), which licenses residential treatment facilities, has also conducted an investigation of the Children's Home.

Two reports resulting from the CMS survey and one from the DSS investigation were provided to the Journal on Tuesday by Gov. Kristi Noem, who said she has read the reports and is reviewing the state’s licensing and regulation of children’s residential treatment facilities. That review includes such issues as the frequency of routine inspections.

“I’m not sure what we have here is a situation that requires legislation, but if it becomes clear that legislation is needed, I will not hesitate to offer up a bill,” Noem said.

Bill Colson, executive director of the home’s parent organization, the private and nonprofit Children’s Home Society, said Tuesday that all of the corrective actions required by the CMS and DSS reports have been implemented.

“Obviously, we regret that Serenity got away from us, we absolutely do,” Colson said. “But I think it’s important to keep in mind that this agency’s been around since 1893, and we’ve served thousands and thousands of kids, and we do it safely. This time, it didn’t work out the way we had hoped, but we’re working to be better.”

The morning of the runaway, after Dennard took off while a staff member attended to other children, the staff at the Children’s Home conducted an initial search for one hour and 41 minutes before calling 911. The newly released reports say that was a mistake.

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The CMS report includes quotes from an interview with the program director at the Children’s Home, Tim Fitzgerald, who said, “It took staff 1.5 hours to contact 911, that should have been done when staff first lost sight of her.”

The Children’s Home had a Lost Child on Campus policy that dated to 1999, according to the CMS report, and one of the steps in the policy was notification of law enforcement.

But the policy was not followed, because staff had not been trained or drilled on it, the CMS report said. The facility now has a new runaway policy that says that 911 must be called immediately, and staff must now receive training, testing and drilling on the policy.

The DSS report also mentioned 911, saying in part, “If a child runs from a staff member and visual contact is lost, 911 must be called immediately.”

Additional quotes from CMS survey interviews with Children’s Home staffers said the initial search for Dennard was disorganized, that no one wanted to assume the role of designated search coordinator, and that the use of three different radio channels — even though there was an option to use an all-call channel — “did not allow everyone to hear the same thing at the same time.”

The disorganization was blamed on a lack of preparation. Any training and drills that had been conducted at the Children's Home were focused on fires, active shooters and lockdown situations, to the exclusion of runaway training.

“Based on interview, record review, and policy review, the provider failed to ensure elopement training and elopement drills were conducted to ensure all staff knew what their roles and responsibilities were in the event of a runaway resident,” the CMS report said.

The report additionally said, in another quote attributed to Fitzgerald, “Complacency amongst the staff was an issue, kids had ran in the past, staff had found them. They thought this time would have been the same.”

The DSS report alluded to Dennard’s behaviors, which her adoptive father and his wife have said includes past runaway attempts.

“Based on the behaviors of the child, identified BHCH staff did not provide the level of supervision required to ensure the safety of the child,” the DSS report said.

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Contact Seth Tupper at seth.tupper@rapidcityjournal.com

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Enterprise Reporter

Enterprise reporter for the Rapid City Journal and author of "Calvin Coolidge in the Black Hills."