summary: 748.2151(d) - Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model

raw_content: During the inspection it was found that four of the children had a discrepancy in the count of medication logged and the amount of medication physically available.

Correction Narrative:
We will implement the DFPS 2993 form as the new standard for medication logs to ensure precise accounting of all medications.

Our current Pharmacy will be requested to provide medication in blister packs. Each pack will be secured by a strong, paper-backed foil to protect the pills until they are dispensed.


state: TX

facility_name: Amor Purus II

summary: 748.2151(b)(1) - Medication record - update cumulative record within 2 hours of administering medication

raw_content: During the inspection it was found that two children's medication logs were blank for the month of June although the medication was still administered.

Category: Medication

Standard Risk Level: Medium High

Corrected at Inspection: No

Correction Narrative:
Upon any medication reviews and changes, the LCCA and the Executive Director will update the medication log with the new medication prescribed by the proper medical professional.

By implementing these steps, Amor Purus II aims to maintain the highest standards in medication management and ensure the safety and well-being of all residents.


summary: 748.151(1) - Operational responsibilities - Designate a qualified full-time child-care administrator

raw_content:
The operation's administrator resigned effective 4/13/24.

On 4/22/24, the operation was provided technical assistance and given 60 days to hire a qualified administrator.

The operation's administrator position continues to remain vacant.

Category: Individual Standards Evaluated

Standard Risk Level: High


summary: 748.3117(b) - Fire Extinguisher-Must keep documentation of annual inspection and/or purchase of new fire extinguishers at operation for review

raw_content: Fire Extinguisher observed in the kitchen pantry was purchased/serviced October 2022.

Standard Risk Level: Medium Low


summary: 748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work.

raw_content: It was reported that a staff member utilized a spatula as a form of punishment. It was reported children were spanked and threatened with the spatula in order to control their behavior.

Correction Narrative: Unnannounced inspection conducted at the operation, interviews were conducted with a child and staff, compliance met.


summary: 748.153(3)(A) - Notification - Change in child-care administrator

raw_content:
The administrator of record for the operation notified CCR on 4/22/24, of no longer being employed at the operation effective 4/13/24.
The operation has not reported the vacancy of the administrator position.


summary: 748.153(3)(C) - Notification - Remove controlling person

raw_content: The operation's administrator resigned effective 4/13/24.


summary: 745.641 - AP Background check results - Must receive notification prior to allowing subject to be present at your operation

raw_content: During the inspection a caregiver was present with a child in care, and the caregiver did not have a background check. That caregiver was immediately removed and replaced by another caregiver.

Correction Narrative: Provider submitted Corrective Action plan via email with the correction of deficiency.  Corrective Action Plan was downloaded in SharePoint. The background check was submitted for the employee and is active.


summary: 748.3701(a) - Recreation responsibility-Must provide daily indoor/outdoor recreational & other activities appropriate to needs, interests, and abilities of children

raw_content: No outdoor activities daily

Deficiency Narrative: No outdoor activities daily

Correction Narrative: Operation emailed new recreational calendar with outdoor and indoor activities.


summary: 748.363(3) - Personnel records-Include current job description

raw_content: Administrator file, no job description

Standard Risk Level: Medium

Deficiency Narrative: Administrator file, no job description

Correction Narrative: Observed updated file at the operation


summary: 748.3239(d) - Evacuation-Must document fire and severe weather drills, including date, time, type of drill, and length of time for evacuation/relocation

raw_content: missing type of drill and time of the drill

Correction Narrative: The operation sent by email an evacuation drill document with the type of drill and time added


summary: 745.4151(c)(5)(A) - Drug testing procedures-All drug testing will at a minimum screen for marijuana, cocaine, opiates, amphetamines, and phencyclidine (PCP)

raw_content: Administrator drug test, no phencyclidine (PCP)

Correction Narrative: Operation provided copy of new drug test with PCP drug testing


facility_name: Angelic House of Hope

summary: 748.311(6) - Serious Incident Documentation-Includes nature of the incident

raw_content: Serious incident report does not reflect the correct information/incident that took place.

Correction Narrative: Angelic House of Hope Administrator and/or Case Manager will conduct weekly audits of all serious incident reports to verify: Accuracy of the narrative, Consistency with supporting documentation, Compliance with DFPS reporting requirements.


summary: 748.303(a)(2)(A) - AP Serious Incdt-Report to Licensing no later than 24 hours after injury/illness that warrants treatment by a medical professional or hospitalization

raw_content: A serious incident requiring treatment by a medical professional or hospitalization was not reported to licensing.

Correction Narrative: Angelic House of Hope staff will receive annual refresher training on reportable incidents.


summary: 748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction

raw_content: Hospital records were not available for review when requested.

Correction Narrative: Angelic House of Hope has implemented to daily monitor all emails sent by HHSC to ensure all requested documents are received.


summary: 748.311(5) - Serious Incident Documentation-Includes names or other means of identifying witnesses to the incident, if any

raw_content: Incident report did not document all staff involved or children.

Correction Narrative: This standard is found to be compliance.


summary: 748.125(f)(2)(A) - Protocols must include weekly screenings for the first 30 days or until the child is no longer reporting suicidal thoughts, whichever is longer.

raw_content: The operation did not conduct weekly screening post hospitalization.


summary: 748.125(g)(2)(B) - You must not leave the child alone until a mental health professional assesses the child, in the event of a suicide attempt.

raw_content: The operation allowed a child to lock herself in the bathroom after having a suicide attempt.


summary: 748.125(c)(1) - Suicide Training-All caregivers and employees must complete at least one hour of annual suicide prevention training.

raw_content: Four of four caregivers did not have suicide risk training.


raw_content: A child was hospitalized and it was not reported as required.

Standard Number / Description: 748.303(a)(2)(A) - AP Serious Incdt-Report to Licensing no later than 24 hours after injury/illness that warrants treatment by a medical professional or hospitalization


Deficiency Narrative: A child was hospitalized and it was not reported as required.


summary: 748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records

raw_content: The remaining amount section of the medication log reflects and inaccurate count of remaining pills in the pill back.

Category: Organization and Administration

Correction Narrative: The operation has come into compliance with this standard.


summary: 748.311 - Serious Incident Documentation-Documented in written report

raw_content: The Serious Incident Form did not include required information such as the operation's address, phone number and the treating licensed health-care professionals name, findings, and treatment.

Correction Narrative: On 8/8/2025, operation staff provided an updated SIR form with the required information.


raw_content: Upon request of staff records, they were unavailable.

Standard Number / Description: 748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction


summary: 748.2953(b) - Evaluation-Operation's quarterly data on EBI's must be reported to Licensing no later than 15 days after the end of each quarter.

raw_content: The operation has not submitted the quarterly EBI report to Licensing after quarter one concluded.

Category: Emergency Behavior Intervention


summary: 748.2151(d) - Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model

raw_content: The medication record for a bedtime medication reflects that there are 24 remaining pills, however the pill pack only has 23 pills.

Correction Narrative:
On 5/23/25 a visit was completed at the operation, at which time medications were reviewed to be in compliance.
The operation advised of the following to correct future concerns:
Medication records will be reviewed three times per week by both the case manager and administrator.

Reviews will be documented on the medication sheet.

If discrepancies are identified, a Medication Error Report will be completed within 24 hours.

The medication sheet will be promptly corrected to reflect accurate and updated information.


raw_content: The Physician named on children pill packs are different than the Physicians listed on the medication record. On another medication, the pill pack advises that the quantity is 30, however the medication record advises starting with 28.

Standard Number / Description: 748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records

Corrected at Inspection: Yes


summary: 748.930(b)(1)(A) - Annual Training-Caregivers in operations other than cottage homes must have 4 hrs of EBI every 6 months.

raw_content: A staffs file shows that the staff member has not completed four hours of EBI every 6 months.

Category: Training and Professional Development

Correction Narrative:
The operation advised of the following to assure that compliance is meet with this standard:

The Executive Director has developed a Monthly Audit Tracker to monitor training compliance.

A training tracker will be placed in each staff member's personnel file to ensure
accountability and visibility of training status.

Staff will receive regular reminders and scheduled opportunities to complete EBI training within the required timeframe.


raw_content: In the reviewing of the serious incident reports regarding an unauthorized absence from the facility, one serious incident report did not have the amount of time the child was away from the facility in the section labeled "How Long?"

Standard Number / Description: 748.311 - Serious Incident Documentation-Documented in written report

Correction Narrative: As correction, the operation will complete all forms with time and the updates as well as continuing to place in the awol binder.


summary: 748.1349(b)(2) - Initial Service Plan- When given to child then child must sign or operation document child's refusal to sign

raw_content: During the review of 3 service plans, all 3 of the child's service plans were not signed by the respected children, and there was also no justification on why the child was not able to sign their service plans.

Standard Risk Level: Low

Correction Narrative: As a correction, the Case Manager, Administrator and Owner will ensure to have a monthly clinical mee􀆟ng to monitor and ensure the implementation of each plan and audits are done correctly and in 􀆟me. During the mee􀆟ng, each individual to check all upcoming service plan and ensure the notifications and completion of service plans are completed in a timely manner.


summary: 748.1335 - Initial Service Plan-Complete the initial service plan within 45 days after admission

raw_content: 4 of the service plans was not competed within the required timeframe.  The child was placed at the facility on 6/18/24 and the 45 day was on 8/2/24, however the service plan was completed late on 10/23/24. A second child's first service plan was completed on 1/23/25 and the child was placed at the facility on 4/23/24, and there is no documentation of a previous service plan being completed. The third child's service plan was completed on 10/29/24 and the child was placed at the operation on 12/23/23, in which the 45-day completion should have been on 2/6/24. The fourth child's service plan reviewed showed that the child was placed on 10/25/23 and the initial service plan was completed on 1/24/25, in which the 45-day completion should have been on 12/9/2023.

Correction Narrative:
As correction the operation advised that A tracker has been created to track assessments and service plan due dates starting at intake. The dates will be entered into google calendar and the tracker will live in each child binders.
The Case Manager, Administrator and Owner will ensure to have a monthly clinical meeting to monitor and ensure the implementation of each plan and audits are done correctly and in time. During the meeting, each individual to check all upcoming service plan and ensure the notifications and completions of service plans are completed in a timely manners.


summary: 748.1341(a) - Initial Service Plan-Must give the child's parent(s) at least two weeks advance notice of the meeting

raw_content: There was no documentation provided by the facility on sending the notification of the service plan meetings to the children's caseworkers. Furthermore, 2 caseworkers interviewed stated that they have not sat in on any of the service plan meetings.

Correction Narrative:
As a correction, the operation stated that the initial service plan that was reviewed was done prior to the current case manager and administrator. All following updated services plans have been in compliance and caregivers have been contacted in advance via email. Moving forward all caregivers will continue to receive at least 2 weeks' notice.
A tracker has been created to track assessments and service plan due dates star􀆟ng at intake. The dates will be entered into google calendar and the tracker will live in each child binders.


raw_content: In the review of documents, one of the child's service plans has 3 medications listed in the health section, and there are 3 different medications added on the Transitional to Adulthood portion. No medication error reports were provided for the following days: 10/8, 10/22, 10/23, 10/24, 10/29, 10/30, 10/31, 11/5, 11/7, 11/8, 11/11 indicating that the errors were most likely not documented. A second child service plan had conflicted information regarding their last annual medical with the first service plan stating that the medical was completed on 12/19/24 while the updated one says 12/5/24, this child also did not have the high-risk section checked for running away on the updated service plan. Lastly, a fourth child's service plan was completed and the service plan stated that the child receives Special Education, but there is no documentation of the child's 504 plan.

Correction Narrative:
As a correction, the Case Manager, Administrator and Owner will ensure to have a monthly clinical mee􀆟ng to monitor and ensure the implementation of each plan and audits are done correctly and on 􀆟me. During the mee􀆟ng, everyone to check all upcoming service plan and ensure the notifications and completions of service plans are completed in a timely manner.

Medica􀆟on: Medica􀆟on will be reviewed 3 x weekly by the Case Manager and/or the Administrator. Staff will be mandated to complete medica􀆟on refreshers and will be required to attend medica􀆟on training quarterly. During the mandated to complete medica􀆟on refreshers and will be required to attend medica􀆟on training quarterly. During the


summary: 748.3301(h) - Physical Site-The building must be free of rodents and insects

raw_content: There are multiple individuals who have stated seeing rodents in the building.

Correction Narrative:
A walk through of the new operation location was completed on 3/27/2025 and no insects or rodents were observed. Follo up inspection conducted by rep Inspection ID#4049290.

Corrections submitted via email 3/19/25:
Operation no longer utilizes the facility at that location. The new location is a new building with no structural issues. In the event that we see signs of insects or rodents in the future this matter will be corrected, and documentation will be available.


summary: 748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.

raw_content: During the walkthrough at the operation, there were observed decomposing pests caught in a trap in one of the bedrooms. There was also observed a hole in the wall in one of the comon areas utilized by youth and staff.

Correction Narrative: An email was received from the operation which included pictures of the dead pests cleaned and no longer present. It also included a picture of the hole in the wall temporarily covered until it can be repaired.


summary: 748.981(a)(1) - First-aid-CPR training-Each caregiver must have current certification in first-aid

raw_content: A caregiver who has been employed since May of 2024 did not have a valid First Aid/ CPR certification until September 2024, as the caregivers last certification expired in November of 2023.

Correction Narrative: Moving forward, if the hired employees do not have current First Aid & CPR certifications, they will be required to complete the training.


summary: 748.753(d)(1) - Pre-Employment-You must document in the employee record each references name, relation, date completed, info obtained and name of interviewer.

raw_content: Staff record is missing pre employment reference check documentation.

Category: Personnel

Correction Narrative: Reference check form has been added to the pre employment packet and will be completed before time.


summary: 748.1531(d) - Medical care-Obtain follow-up medical treatment as recommended by the health-care professional

raw_content: There is no documentation to show that a child attended the recommended follow appointment after the child's 7/1/24 medical appointment.

Category: Child Care

Correction Narrative: The Case Manager and Operation Manager will ensure to schedule a follow up appointment immediately following the initial appointment if required. The documentation will be filed by the Case Manager and Operations manager.


summary: 748.1103(a) - Informing child of rights-Review rights with child/parents within 7 days of child's admission; provide child/parents with written copy of rights

raw_content: A child resided at the operation for 3 months prior to child rights being reviewed with the child.

Category: Children's Rights

Correction Narrative: The child's rights will be completed during the initial intake and will be added into the intake packet.


summary: 745.651(1) - Background Check Validation - You must inactivate a subject who is no longer associated with your operation within 7 days of leaving

raw_content: There are several people with active backgrounds checks for the operation who no longer work for the operation.

Correction Narrative: As a operation, we will continue to inactivate people who no longer work with the operation and they will be removed no later than 7 business days.


summary: 748.1545(a) - Vision and hearing screening-must ensure that each child is screened; must have professional exam if problems are detected

raw_content: There is no documentation in the children's files, that a vision or hearing exam has been completed.

Correction Narrative: The child has a vision and hearing exam completed. The case manager and operations manager will ensure all files are placed inside the specific child file once received.


summary: 748.1225(b) - Admission-Dental exam for child 3 years old or older scheduled in 30 days and done in 90 days unless documentation of one within past year on file

raw_content: There is no documentation in the child's file reflecting that the child has had a Dental Exam completed.

Correction Narrative: Going forward, operation will continue to ensure records reflect initial dental exams are scheduled in 30 days and done in 90 days unless documentation reflects


summary: 748.1531(b)(4) - Medical Care-If exam is due to injury or illness, record of medical exam documents date/time & circumstances of injury/illness

raw_content: There are a number of medical appointment reports that are missing multiple pages of information relating the reason for the medical visit.

Correction Narrative: The operation will begin immediately ensuring the entirety of the form k-905-2403 is completed by the case manager, operations manager and physicians.


summary: 748.1387 - Service Plan Review-Must comply with notification, participation, implementation, and documentation requirements for an initial service plan

raw_content: The service plan review requirements such as notification was not observed. In addition, the service plan review was not signed by any of the parties who were supposed to participate. There was no signature or date to indicate that participation took place or that a copy was provided.

Correction Narrative: The operation has come into compliance with this standard.


summary: 748.3395(b)(4) - Hand-washing-Provide hand-washing sinks equipped with soap & a personal towel, single-use disposable towels, or hot air hand dryers

raw_content: During the walkthrough two bathrooms were observed to be without disposable towels, or any device to dry hands after use.


summary: 748.3421(3) - Poisons-Ensure poisonous/flammable material isstored in an area that is inaccessible to children unless child is capable to use responsibly.

raw_content: During the walkthrough it was discovered that poisonous/flammable material are stored under the cabinet sink unlocked and accessible to children.


summary: 748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records

raw_content: It was observed that a child's file is not current due to the initial service plan not being in the file as well as the reviews thereafter.


Deficiency Narrative: It was observed that a child's file is not current due to the initial service plan not being in the file as well as the reviews thereafter.

Correction Narrative: All documents will be placed in childs files as recieved 24 hours after obtained.


summary: 748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders

raw_content: It was observed that the health-care professional's orders were to administer a cream to the affected area 2 times per day however the child has not been taking it daily and the times the child did apply the cream it was done once a day. In addition, the same child is not receiving one of their medications.


summary: 748.2203(c) - Medication Error-Operation must meet documentation requirements within 24 hrs

raw_content: There is no documentation regarding missed doses of medication.

Correction Narrative:
All staffed will continuously be trained on medication and medications will be reviewed by LCCA and case manager weekly.
An inspection was completed on 12/4/24 and all medication was reviewed showing all medications taken were documented.


summary: 748.2307(8) - Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child

Correction Narrative: 748.2307(8) Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child	It was reported by an employee and children that an employee had a history of cursing and yelling at and around the children.	Y	The agency should conduct a meeting with all staff and discuss the prohibited discipline, punishment and conduct outlined in Minimum Standards. The agency should consider utilizing frequent reminders of such conduct during training sessions and brief meetings. Frequent reminders can convey the subject is important to the organization and possibly reduce such incidents. The avoidance of yelling and cursing by staff can also aid in treatment. This can reduce children from being triggered and also set a positive example	A quality assurance survey is implemented into the program. All staff will be retrained on Mandated reporting to ensure they are not just hearing or witnessing but reporting and understanding what being a reporter is.  	Mandated Reporting retraining will be required and all DCS will have it completed by 5/1/2024


summary: 748.4003(1)(C) - General requirements-When transporting a child the operation must ensure each driver has a current driver's license for the type of vehicle used

raw_content: A staff member transporting children does not have a valid Texas driver's license.

Correction Narrative: All employees will be required to provide a driver's license, the license will be run for drivers' clearance and the staff will be added to the approved drivers list. Our current drivers are documented on the attached approved drivers list. A current list of drivers has been provided on separate document.


summary: 748.705(b)(10) - Reasonable & prudent parent standard-must consider the importance of providing the child with the most normal family-like living experience possible

raw_content: Childrens belongings were packed in trash bags when they moved from the operation.

Correction Narrative: We have boxed and spare bags. Staff were given a training reminder that items are not to be packed in trash bags. The staff who gave the instruction to use the trash bags was reprimanded and is no longer with the operation.


summary: 748.869(c) - Training on administering psych. medication must be instructor-led. The instructor must be a health-care professional or pharmacist.

raw_content: All staff records reviewed did not have the instructor led portion of the psych. medication training in their record.

Correction Narrative: Certificates for the training from a professional has been received	All certificates are being added to the files and a file review will be conducted to ensure all documents there.


summary: 748.2151(d) - Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model

raw_content: Medication records reviewed did not have a written area for the number of meds left after administration.

Correction Narrative: Infromation was Added to new sheet and a New sheet was created.


summary: 748.2151(a) - Medication Record-Maintain cumulative record of prescription medications dispensed to child, include nonprescription meds for child under five yrs old

raw_content: One out of the three children's records observed was missing a medication log for a psychotropic medication. The operation created the medication log for this medication during the inspection.


summary: 748.863(a)(1) - Pre-Service Training-All caregivers must receive 8 hrs of general pre-service training & 4hrs before being counted in child/caregiver ratio.

raw_content: All three staff records reviewed were missing some components for the general preservice training such as - normalcy, trauma informed care, and spread of communicable diseases.

Correction Narrative: All staff files are being reviewed, the certificates for some of the missing have been retrieved, training check lists are being created for the 40 hours OJT and preservice alone with the general training. 	All files will be reviewed to make sure all training are in them and identified by a training sheet. It will have the trainer, the credentials of the trainers if needed and the hours.


summary: 748.125(e)(1)(A) - You must immediately refer a child to a MH professional for a suicide risk assessment if screening finds child to be at a high risk for suicide.

raw_content: A child in care was not referred to a mental health professional after scoring high on the suicide risk assessment completed at admission.

Correction Narrative: AHOH will make sure the your who test high for an risk assessment will be referred to a MHP immediately.


summary: 748.1205(a)(12) - Admission Documentation-Identification of child's high risk behaviors and related safety plan staff and caregivers will implement

raw_content: During the course of the observation, it was found that a safety plan was not implemented to address the child's high-risk behavior at the time of admission.

Correction Narrative: The operation has implemented their own safety plans at admission when a child exhibits high risk behaviors.


summary: 748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks

raw_content: Staff did not respond timely to a child verbally expressing suicide ideation.

Correction Narrative: When children express high risk behaviors, operation staff will ensure those children are taken timely for mental health evaluation.


summary: 748.1331(a) - Preliminary Service Plan-Complete plan that addresses child's immediate needs within 72 hours of admission

raw_content: A 72-hour Service plan was not completed for a child in care.

Correction Narrative:
The operation had the child's 72 hour plan in their records.
 The email requested by investigator said 72 hour plan and/or safety plan.


summary: 745.4151(c)(5)(B) - Drug testing procedures-Drug testing will use one of these drug-testing methods: certified lab, appropriate testing kit or other comparable method

raw_content: The staff records reviewed showed did not show the method used for the drug screening with the results

Correction Narrative: Photos of the staff test were emailed previously and were printed and added to their files.


summary: 748.1205(a)(10) - Admission Documentation-Includes known contraindications to the use of restraint

raw_content: The children records reviewed did not address known contraindications of restraints.

Category: Admission, Service Planning, Discharge

Correction Narrative: Forms have been corrected and printed for the client's binders.


summary: 748.1337(b)(1)(N) - Initial Service Plan-Include signatures of service planning team members that were involved in development of service plan

raw_content: Children's records reviewed did not have the signature page for their service plans.

Correction Narrative: All signature pages will be added once all signatures are received.


summary: 748.1337(b)(1)(H)(i) - Initial Service Plan-For child who exhibits high risk behaviors, include plans to minimize risk of harm to self or others

raw_content: One of the child's records reviewed did not address their high risk behaviors.

Correction Narrative: Corrections made in all files of current clients.


summary: 748.457(a) - Unauthorized AbsenceTriggered Review of childs unauth absences must occur ASAP, but no later than 30 days after third absence within 60-days

raw_content: During the investigation it was found that the operation did not conduct a triggered review for a child in care.

Correction Narrative: The operation updates their AWOL procedure to include that trigger warnings will be conducted when a child runs away three times within 6 days.


summary: 748.453(a)(1) - Unauthorized Absence  Annual summary log must include name, age, gender, date of admission

raw_content: During the investigation it was found that the operation does not have an unauthorized absence log.

Correction Narrative: An unauthorized absence log was created. The operation will ensure that they document each AWOL on the running log.


summary: 748.125(g)(2)(A) - You must immediately call emergency services and render first aid until professional medical treatment can be given.

raw_content: Based on the review of the investigation, it was determined that the operation did not provide first aid to a child in care after contacting EMS.

Correction Narrative: AHH staff attended a training on 11/7/2023 Staff were trained on when first aid was to be done, what to do if the client refuses, making sure to document the first aid on all documents and follow up on and injuries with management.


summary: 748.363(3) - Personnel records-Include current job description

raw_content: One staff record on file did not include the current job description for each.

Category: Reports and Record Keeping

Correction Narrative: Email sent showed that the files contained current job descriptions.


summary: 745.4151(c)(4)(A) - Mandatory drug testing-all applicants intended to be hired are subject to pre-employment testing, must have results prior to child access

raw_content: The 2 files reviewed did not contain the requisite drug test results prior to child access.

Correction Narrative: The 2 files contained the drug test results for the employees concerned.


summary: 748.363(6) - Personnel records-Include notarized Licensing Affidavit for Applicants for Employment form as specified in Human Resources Code, 42.059

raw_content: The 2 staff records did not contain the notarized Licensing Affidavit for Applicants for Employment.

Correction Narrative: Email sent showed that the Licensing Affidavit for Applicants for Employment have been duly notarized.


summary: 748.1583(a) - TB exam-Persons over 1 yr old who live, work, volunteer at facility have exam w/in 30 days, unless person had previous exam that meets requirements

raw_content: Records reveal that the TB test result for the Treatment Director is not on file.

Correction Narrative: Email received showed that the TB test result for the Director is on file.


summary: 748.363(8) - Personnel records - Include signed dated statement by the employee that he must immediately report suspected child abuse, neglect, or exploitation.

raw_content: The 2 staff records reviewed revealed that there was no signed and dated document pertaining to reporting suspected child abuse, neglect, and exploitation.

Correction Narrative: The 2 staff records showed a signed and dated document relative to reporting suspected child abuse, neglect, and exploitation.


summary: 748.533(a)(5) - Child-care administrator-Can be administrator for two operations if the Operations are contiguous

raw_content: Records reveal that the present Administrator is currently an Administrator for another operation. Both operations are not contiguous.

Correction Narrative: The current administrator is no longer an administrator for another facility.


summary: 748.363(7) - Personnel records - Include statement signed and dated by the employee that he has read a copy of the operational policies

raw_content: The 2 staff records reviewed did not include the date and signature of the employees evidencing that they have read the facility's operational policies.

Correction Narrative: The 2 staff records contained a signed and dated statement that the staff have read the facility's operational policies.


summary: 748.363(9) - Personnel records-Include proof of request for background checks

raw_content: A scrutiny of the files on 2 staff reveal that there was no request for the conduct of a background check prior to employment.

Correction Narrative: The 2 personnel records contained the requisite request for the conduct of a background check.


summary: 748.1205(a)(4) - Admission Documentation-Includes names, addresses, telephone numbers of siblings

raw_content: The admission assessment was missing a space for sibling contact information and suicide screenings.


raw_content: The staff record did not contain the required affidavit for employment.

Standard Number / Description: 748.363(6) - Personnel records-Include notarized Licensing Affidavit for Applicants for Employment form as specified in Human Resources Code, 42.059


facility_name: East Texas Open Door Inc

summary: 748.125(d)(4)(D) - Suicide Screening- Must be administered every 90 days after admission for children 10 years of age or older in a GRO that is not a RTC.

raw_content: The operation has not been administering suicide screenings every 90 days as required by minimum standards.

Correction Narrative: Meagan Doan had been out of town. Sent correction as of 3/31/26, showing staff will be completing initial suicide screenings at intake and entering it in Casebook. Casebook will notify staff when a child's 90-day screening is approaching.


summary: 748.3233(b)(3) - Evacuation-Emergency evacuation & relocation diagram must include designated location inside operation to take shelter from threatening weather

raw_content: During the after-hours monitoring inspection, it was observed that the operation's posted evacuation diagrams did not have a specified shelter in place location for severe weather.

Correction Narrative: On 9/5/2025, the operation's Administrator provided an updated emergency evacuation plan to include the designated shelter in place area, that was previously missing.


summary: 748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety

raw_content: The caregivers did not de-escalate a heated altercation between two residents, which resulted in a child having a seizure and requiring emergency medical attention.


summary: 748.3443(b)(2) - Food Preparation-Must have a thermometer in freezers & store frozen food at 0 degrees Fahrenheit or below

raw_content: During the monitoring inspection, the thermometer located in the freezer was not at the required 0 degrees.

Category: Physical Site


summary: 748.535(2) - AP Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.

raw_content:
During a review conducted on March 25, 2024, it was determined that:
(1) the Administrator failed to ensure compliance with the current HM Plan; and
(2) 12 months had elapsed since the effective date of the plan.
The heightened monitoring plan for this operation included a specific planned end date at the 12-month mark by which the operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of post plan monitoring.  As a direct result of the administrators failure to ensure timely compliance with the heightened monitoring plan, this operation is now unable to successfully move to post-plan monitoring.  Furthermore, the operations planned end date must now be revised, and the period of heightened monitoring must be extended.
Further details of the administrators failure to ensure compliance include the following:
- Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring and
- Operation was unable to meet compliance with Medium-High or High weighted licensing citations

Correction Narrative: An HM extension was approved effective March 25, 2024.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your CPA in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 749.635(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is September 26, 2024.


raw_content:
During a review conducted on September 22, 2023, it was determined that:
(1) the Administrator failed to ensure compliance with the current HM Plan; and
(2) 12 months had elapsed since the effective date of the plan.
The heightened monitoring plan for this operation included a specific planned end date at the 12-month mark by which the operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of post plan monitoring.  As a direct result of the administrators failure to ensure timely compliance with the heightened monitoring plan, this operation is now unable to successfully move to post-plan monitoring.  Furthermore, the operations planned end date must now be revised, and the period of heightened monitoring must be extended.
Further details of the administrators failure to ensure compliance include the following:
- Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring and
- Operation was unable to meet compliance with Medium-High or High weighted licensing citations

Standard Number / Description: 748.535(2) - AP Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.

Correction Narrative: An HM extension was approved effective 9/22/23.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your GRO in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 748.535(2). The HM deadline for your operation has been extended by 6 months and the new deadline is March 23, 2024.


summary: 748.3395(b)(4) - Hand-washing-Provide hand-washing sinks equipped with soap & a personal towel, single-use disposable towels, or hot air hand dryers

raw_content: During the inspection, the bathroom in bedroom four had a paper towel dispenser but no paper towels.

Correction Narrative: On 9/7/2023, a second investigation inspection was conducted and it was observed that paper towel dispenser was stocked with paper towels for use.


summary: 748.3301(a)(1) - Physical Site- Buildings must be structurally sound and not pose a risk to the health and safety of children.

raw_content: During the inspection, it was observed that the door to access the attic was unlocked and accessible to children who were permitted to be upstairs.

Correction Narrative: On 9/7/2023, a second investigation inspection was conducted and it was observed that the attic door was locked.


raw_content: During a walkthrough of the operation, I observed two freezers with non-working thermometers.

Standard Number / Description: 748.3443(b)(2) - Food Preparation-Must have a thermometer in freezers & store frozen food at 0 degrees Fahrenheit or below

Correction Narrative: On 9/7/2023, a second investigation inspection was conducted and it was observed that operation had replaced the thermometers in both freezers and they were working appropriately.


summary: 748.3239(b) - Evacuation-Must practice severe weather drill at least once every 6 months from date of last severe weather drill

raw_content: During the inspection, it was discovered the operation has not completed a severe weather drill in over 12 months.

Correction Narrative: On 9/14/2023, ETOD administrator provided a copy of fire and emergency drills completed on 9/14/2023.


summary: 748.3233(b)(4)(C) - Evacuation-Emergency evacuation & relocation diagram includes at least 2 exit routes that are not through a kitchen or other hazardous area

raw_content: During the investigation, it was observed that the operation's evacuation plan has one exit that leads directly through the kitchen.

Correction Narrative: On 9/29/2023, the Asst Fire Marshal with Marshall FD, Lt. Siler, provided documentation to reflect the FD is working with the operation to evaluate the plans and bring all plans in to compliance. On 10/9/2023, the administrator advised ETOD received compliance with the local Fire Marshall last year October 2022 which is valid until October 2023 regarding the Emergency Evacuation routes.  The Fire Marshall recommendations/ approval of route trumps the Licensing standards.  However, due to investigation and at the command of Licensing, a more detailed report was needed to be in compliance with the above standard.  ETOD reached out to Fire Marshall for a more detailed compliance report to provide to Licensing.  Upon speaking to the Fire Marshall, he stated he would come up with an alternative route or approve the route already in place if a secondary route did not prove to be more appropriate.  Copies of the evacuation routes were provided to Fire Marshall with the understanding that the route must be provided to ETOD by 10/09/2023.  At this time, routes have not been provided and ETOD in awaiting this approved recommended route by the Fire Marshall to ensure compliance is met.  Countless phone calls and visits to the Fire Marshall's office were made, but we were unsuccessful.  We will continue to call and personally go to the station to press the urgency of this matter.


summary: 748.3233(b)(4)(E) - Evacuation-Emergency evacuation & relocation diagram includes 2 exit routes that are not doors or windows that require key to open from inside

raw_content: During the investigation, it was observed that the operation's back gate was locked with a padlock. The emergency evacuation plan instructs children to meet at the large parking lot across the street, however, those who exit through the back door will not be able to open the gate without a key to the padlock.

Correction Narrative: On 9/7/2023, RCCR observed the lock being removed by maintenance during the inspection. On 9/29/2023, the Asst Fire Marshal with Marshall FD, Lt. Siler, advised the lock was removed. On 10/9/2023, the administrator advised ETOD removed the padlock on the fence that separated the meeting place during an evacuation and the backyard of the home.


summary: 745.641 - AP Background check results - Must receive notification prior to allowing subject to be present at your operation

raw_content: It was relayed to Childcare Regulation that the spouse of a staff person at the facility began living at the operation in the beginning of August 2023. The Administrator confirmed this information to DFPS. A background check was not submitted prior to this person moving in.

Correction Narrative: The operation submitted the individual for a fingerprint check.


summary: 748.2003(b)(5) - Administration of prescription medication-Ensure the child has taken the medication as prescribed

raw_content: A child in care received medication 4 hours later than it was to be received.

Correction Narrative:
The following information was submitted by Shan Dunn, Administrator as a corrective action for the citation issued above.  Administrator will assign one designated staff member to administer medication to all youth in care for 7am,12pm & 3:30pm (if applicable), and 8:30pm medications.  In addition to the assigned person who will be responsible for administering medications to youth, there will be an assigned on  call backup person who will be responsible for administering medications to youth in the event of an emergency or the designated person is unable to administer the medications for whatever reason.   The designated medication administer and on-call person will be responsible for ensuring all medication are given to youth within 2 hours of prescribed time while in the home or away from the home (example: camp, outing, or other event).
In addition, all designated staff members will undergo a refresher medication administration training no later than 12/15/2023. This training will be facilitated by the Administrator or Assistant Administrator and will consist of minimum standards related to medication administration.


summary: 748.2101(1) - Medication Storage-Store medication in a locked container

raw_content: During the inspection, there was an unlocked box of over the counter medication on a book shelf in the conference room, which children have access to.


summary: 748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair

raw_content: During an inspection, there was excessive dust and cob webs on vents, walls, and ceilings.


summary: 748.1101(b)(4)(A)(v) - Children's rights- To be free from being subjected to remarks that belittle or ridicule the child or the child's family

raw_content: Three of the five children interviewed reported that a staff provoked children in care by making belittling and ridiculing comments and laughing at the children, which resulted in a staff being assaulted.

Correction Narrative: The operation sent an email of an Employer Disciplinary Action for staff that were listed in the investigation. The letter stated they were not in agreement with this determination, and an administrative review has been requested. The letter was a written reprimand for the citation. Upon the decision of the Admin Review, if overturned, the reprimand will be voided. If the reprimand is not overturned, further disciplinary action must be taken and will be discussed at that time. Until the determination, both staff will not be able to work in the home supervising the residents, unless supervised by the Administrative Team Staff


raw_content:
During a review conducted on March 17, 2023, it was determined that:
(1) the Administrator failed to ensure compliance with the current HM Plan; and
(2) 12 months had elapsed since the effective date of the plan.
The heightened monitoring plan for this operation included a specific planned end date at the 12-month mark by which the operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of post plan monitoring.  As a direct result of the administrators failure to ensure timely compliance with the heightened monitoring plan, this operation is now unable to successfully move to post-plan monitoring.  Furthermore, the operations planned end date must now be revised, and the period of heightened monitoring must be extended.
Further details of the administrators failure to ensure compliance include the following:

- Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and
- Operation was unable to meet compliance with Medium-High or High weighted licensing citations.

Correction Narrative: An HM extension was approved effective 3/20/23.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your GRO in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 748.535(2). The HM deadline for your operation has been extended by 6 months and the new deadline is September 21,2023.


summary: 748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.

raw_content: During the inspection, there was a hole in the wall in bedroom 2.


summary:
748.3421(3) - Poisons-Ensure poisonous/flammable material is
stored in an area that is inaccessible to children unless child is capable to use responsibly.

raw_content: During the inspection, there was a bottle of Scrub Free Total Bathroom Cleaner on a shelf in the living area.


summary: 748.3115(3) - Fire Extinguisher-Must ensure fire extinguishers are serviced as required by manufacturer's instructions, or as required by fire inspector

raw_content: During the inspection, the fire extinguisher in the attic/game room of the grey home had expired tags and reflected the last service date of Sept 2020.


raw_content: During the inspection, the freezer combo in the grey home did not have a thermometer.

Correction Narrative:
On 2/27/23, the operation's administrator provided the corrective actions for deficiencies received on 2/16/23. They advised cooks and dietician will check for thermometers in the appropriate places each week as well as check for any expired food and ensure that food is appropriately labeled and stored. Dietician will complete a check on all of the freezers and fridges each Wednesday. Cook will complete a check on the same each Saturday.

Photographs were provided to reflect the operation has installed a thermometer in the freezer on 3/3/23.


summary: 748.2551(d)(1) - EBI Implementation-Caregiver must make every effort to protect the child's privacy, including shielding the child from onlookers

raw_content: During the investigation, it was discovered that the caregivers did not attempt to shield the restraint of a child from other residents that were present.

Correction Narrative: On 4/10/2023, East Texas Open Door's Administrator provided a corrective plan for the deficiencies to include: requiring Shan Dunn and Dee Dee Dixon will need to be enrolled in an EBI training course to be conducted by an outside entity within 30 days (APRIL 30, 2023). Upon completion of training, Shan and Dee Dee must participate in refresher course trainings every 6 months in addition to the CPI (EBI) Instructor training every two years. This must be completed by the CPI corporation virtually or in person.


summary: 748.2551(c)(2) - EBI Implementation-Caregiver must use the minimal amount of reasonable and necessary physical force

raw_content: During the investigation, it was determined that the caregivers did not use the minimal amount of reasonable and necessary physical force during an EBI implementation as they can be seen, on video footage, sitting on and straddling the child.


summary: 748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being

raw_content: It was discovered through interviews with collaterals, that staff failed to supervise children accordingly, as staff member would fall asleep during their working hours.

Correction Narrative:
The staff member involved is no longer employed at the operation.

*Overnight pop up visits (conducted by ETOD staff members) will occur at least twice a month in addition to the overnight monthly visits that contract conducts. This will be a total of three overnight pop up visits each month.
*Any employee who is alleged to be sleeping on shift will receive the appropriate reprimand according to the policy and procedure manual. This could include a written reprimand/warning, probation or immediate termination. If an employee is not terminated, said employee will not be the sole caregiver for any client for up to 180 days (but no less than 45) during which they will have monthly progress meetings with the supervisor. These progress meetings will include feedback from staff who work with said employee.
*Any employee may be suspended without pay for up to three days according to policy.


summary: 748.2151(b)(1) - Medication record - update cumulative record within 2 hours of administering medication

raw_content: During the inspection, I observed three missing medications documentation entries in one child's record.

Correction Narrative:
On 12/8/22, I, Eric Sjerven, received an emailed document from Lashandria Dunn, administrator, detailing the actions and plan to be taken by the facility to ensure ongoing compliance with this standard.  The plan includes the following steps:
Both medical liaisons, lead workers 1 and 2, Case manager, and Administrator will be responsible for ensuring that medication logs are reviewed for errors within 2 hours of administration, and a daily schedule was provided via email on 12/10/22 as an example of how the operation intends to track who will be reviewing the meds each day.  Those reviewing the logs will initial on the date they reviewed the log.  The administrator will complete a weekly audit of all resident med logs and medication to ensure reviews are being completed timely and efficiently.

The administrator also included that all designated personnel administering medication must have a monthly medication refresher meeting in which documentation of medication, storage of medications, medication safety tips, etc. will be discussed.  This meeting will be facilitated by the Lead Worker 1 and will occur on the first Tuesday or Friday of each month.  The administrator indicated that sign in sheets, agendas, and acknowledgment forms are to be completed.

The administrator also included a plan that stated:  if an error is found by the Administrator; the responsible personnel will be removed from giving meds and if the personnel review medication administration raise of $1 was applied to their salary, this will be docked for a period of time as determined by the Administrator.

Based on this plan, the operation can be considered in compliance of this standard as of 12/8/22.


summary: 748.535(2) - AP Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.

raw_content:
During a review conducted on 9/16/22, it was determined that:
(1) your operations administrator failed to ensure compliance with the current HM Plan(s); and
(2) 12 months had elapsed since the effective date of the plan.

The heightened monitoring plans for this operation included a specific planned end date at the 12-month mark by which the operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of post plan monitoring. As a direct result of the administrators failure to ensure timely compliance with heightened monitoring plans, this operation is now unable to successfully move to post-plan monitoring.  Furthermore, the operations planned end date must now be revised, and the period of heightened monitoring must be extended.
Further details of the administrators failure to ensure compliance include the following:

- Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and
- Operation was unable to meet compliance with Medium-High or High weighted licensing citations, including having an open investigation.

Correction Narrative: An HM extension was approved effective 9/22/2022.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your CPA/GRO in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 748.535(2).  The HM deadline for your operation has been extended by and the new deadline is 6/9/2023.


summary: 748.3301(a)(3) - Physical Site- Buildings must comply with applicable building, plumbing, electrical, fire, and similar codes.

raw_content: During the walk through of the operation exposed wire was found near the central fire detector system.


summary: 748.311 - Serious Incident Documentation-Documented in written report

raw_content: On 5/30/22 there was a report of four clients testing COV-19 positive diagnosis.  There was no documentation available for review of this incident during my inspection

Correction Narrative: During today's HM Inspection I reviewed the serious incident reports for the four clients who tested positive.  The reports were completed on 6/10/22 by the Administrator, Shan Dunn.


summary: 748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks

raw_content: Staff ran a personal errand while transporting children in care.

Correction Narrative: An email was received from administrator. The document will be located in SharePoint. The document was a memo shared with all staff about the citations. The administrator addressed the following: TIPS: USE YOUR BEST JUDGEMENT WHEN INTERACTING AND MAKING DECISION REGARDING THE CHILDREN IN OUR CARE.  THINK BEFORE YOU SPEAK OR ACT.  REMEMBER THESE CHILDREN ARE VULNERABLE AND WE ARE OBLIGATED TO KEEP THEM SAFE, MAKE THE BEST DECISIONS ON THEIR BEHALF, AND AWARE OF THE BEHAVIORS AND NEEDS OF THE CHILDREN IN OUR CARE.


summary: 748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language

raw_content: Several children indicated staff uses profane language towards children in care.

Correction Narrative:
An email was received from administrator. The administrator address staff with a memo. Staff were told to sign the memo for understanding. The memo stated the following: TIPS: THE PURPOSE OF THIS RULE IS TO PREVENT HARM TO CHILDREN DUE TO THE USE OF BEHAVIOR MANAGEMENT TECHNIQUES THAT EMOTIONAL PAIN OR DISCOMFORT. THESE PROHIBITED METHODS OF PUNISHMENT ARE CONSIDERED PHYSICALLY, PSYCHOLOGICALLY AND/OR EMOTIONALLY ABUSIVE.
APPLYING THIS WHILE ON DUTY: REMEMBER, THESE CHILDREN ARE IN OUR CARE DUE TO SOME TYPE OF ABUSE OR NEGLECT DIRECTLY OR INDIRECTLY.  THIS IS MORE REASON THEN EVER FOR US TO BE MINDFUL IN OUR INTERACTION WITH THEM.  IT MUST BE APPROPRIATE, PROFESSIONAL, AND ETHICAL.  THEY HAVE BEEN HURT IN ALL WAYS EMOTIONALLY, PHYSCIALLY, AND SEXUALLY, AND WE AS THEIR CAREGIVERS MUST ENSURE THAT WE DO NOT RE-TRAUMATIZE THEM WITH ANY TYPE OF ABUSE.


summary: 748.1101(b)(4)(A)(ii) - Children's rights-The right to be free from being subjected to or threatened with corporal punishment, including spanking or hitting

raw_content: Several children indicated staff threatened to physical harm children in care.

Correction Narrative:
An email was received from the administrator. The email indicated that the administrator addressed a memo with staff. The memo indicated the following:DURING A CRISIS SITUATION IN WHICH EBI (PHYSICAL OR VERBAL INTERVENTION) MAY BE NEEDED, PLEASE BE SURE TO PHRASE STATEMENTS IN A NON-THREATENING MANNER.  IN CASES OF BULLYING, PHYSICAL AGGRESSION, VERBAL AGGRESSION/THREATS, USE VERBAGE THAT WILL LEAST LIKELY ESCLALTE THE SITUATION.
FOR EXAMPLE: INSTEAD OF STATING, I'M GOING TO CALL THE POLICE ON YOU OR IF YOU DO THAT AGAIN, YOU'RE GOING TO JAIL, SAY THIS INSTEAD IF YOU DO NOT STOP SAID BEHAVIOR, I WILL HAVE TO DO WHAT'S NECESSARY TO KEEP YOU AND OTHERS SAFE. REMEMBER, IT'S ALL ABOUT HOW YOU SAY THINGS.  THE GOAL IS TO KEEP THE CHILD FROM ESCLATING IN BEHAVIOR, REMAINING PROFESSIONAL, AND IF CRISIS DOES ARISE IN SPITE OF YOUR BEST EFFORTS, YOU WORKING DELIGENTLY TO GET THE CHILD BACK TO A CALM PLACE IN WHICH THERAPEUTIC SUPPORT CAN BE GIVEN.  RESTORE THE RELATIONSHIP!


raw_content: The caregiver did not use prudent judgment when she asked the other residents to help her to physically control the child who had swallowed glass.  The caregiver chose to look for more glass in the bedroom while this was happening.  The victim child could have been seriously injured.

Standard Number / Description: 748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks

Correction Narrative: 1.5 hours of training is being given to all staff and also reviewed with the children regarding EBI issues, protocol, supervision, and prudent judgment.  The topics being reviewed are detailed in the email send by Ms. Shan Dunn and uploaded into  digital storage.  A follow up inspection  is also being done on July 19, 2022.


raw_content: There were three girls on this child.  One straddling her torso, one holding her head, and one holding her ankles.  This could have caused pain, panic, or breathing problems for the child being restrained.

Standard Number / Description: 748.2551(c)(2) - EBI Implementation-Caregiver must use the minimal amount of reasonable and necessary physical force

Correction Narrative: 1.5 hours of training is being given to all staff and also reviewed with the children regarding EBI issues, protocol, supervision, and prudent judgment.  The topics being reviewed are detailed in the email send by Ms. Shan Dunn and uploaded into  digital storage.  A follow up inspection  is also being done on July 19, 2022.  Inspection was completed.


summary: 748.2855(a) - EBI Documentation-Caregiver must document EBI in child's record as soon as possible, but no later than 24 hours after initiation of the intervention

raw_content: There was no documentation of this EBI restraint.


summary: 748.2453 - Emergency Behavior Intervention-Only a qualified caregiver may administer emergency behavior intervention, except short personal restraint

raw_content: A caregiver asked the other children in the home to help her restrain a child who needed to be hospitalized. The restraint was conducted by untrained teenagers.

Correction Narrative: 1.5 hours of training is being given to all staff and also reviewed with the children regarding EBI issues, protocol, supervision, and prudent judgment.  The topics being reviewed are detailed in the email send by Ms. Shan Dunn and uploaded into  digital storage.  A follow up inspection  is also being done on July 19, 2022.  Follow inspection was complete.


summary: 748.2851(c)(2) - EBI Follow-Up-Caregivers involved in EBI must make reasonable efforts to debrief with children in care who witness the incident

raw_content: There has been nothing shared verbally or in writing by the children or staff that the situation was discussed with them.


summary: 748.2851(b) - EBI Follow-Up-Caregivers involved in EBI must conduct a post discussion with child

raw_content: The child did not have a post discussion with a caregiver after she was restrained by the children.


summary: 748.2853(1) - EBI Documentation-Date and time the caregiver offered the post discussion to the child

raw_content: In one of the restraint reports, there was nothing under the "debriefing" section.  In two other reports, the documentation was minimal and lacked detail.

Correction Narrative: A review with staff regarding the steps that are required to be taken before using any type of restraint.  They are also being retrained in a staff meeting about everything that needs to be documented after a restraint.  This will cover corrections for both deficiencies, and the form is in digital storage.


summary: 748.2551(a) - EBI Implementation-Must be an appropriate response to the behavior demonstrated, and de-escalation must have failed

raw_content: One staff chose to use a restraint on a child when the situation, as written, did not constitute an emergency.


summary: 748.1583(a) - TB exam-Persons over 1 yr old who live, work, volunteer at facility have exam w/in 30 days, unless person had previous exam that meets requirements

raw_content: One of the four children read had no TB test or results in the chart.

Correction Narrative: Email sent showing the TB test for the child with the missing test. See digital storage.


raw_content: At least one staff member has been dozing off during  her graveyard shifts and has been  seen sleeping by more than one child.

Standard Number / Description: 748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being

Correction Narrative: An email  was sent stating that a formal reprimand was made against the  caregiver.  Also, all caregivers have signed rules with plans and ideas to stay awake while at work.  An inspection was completed on 4/7/21 to follow up.


raw_content: The general responsibilities of all employees regardless of whether they are counted in the child/caregiver ratio is to demonstrate competency and prudent judgement in the absence of a more specific rule requirement. In this incident the two children were involved in a verbal altercation 30 min prior to arriving back at the facility, once at the facility one of the children is refusing to take verbal direction from staff and is attempting to make contact with the second child. While staff offered a chance to go to a separate house that evening, the second child refused and chose to return to "White house". Even after staff observed the other child outside and heard her making derogatory comments, they allowed the second child to return to her assigned housing where the altercation occurred.

Correction Narrative: The administrator indicated that in the future situations like this in which there are residents who seem hostile will be separated and if they refuse, the police will be call for assistance in the separation


summary: 748.2101(3) - Medication Storage-Store medication covered by Schedule II of the Texas Controlled Substances Act under double lock in a separate container

raw_content: The medication boxes at both the White and Corner House was observed during today's inspection, and both were in locked closet but the boxes were not locked.  When the individual boxes are not locked it operation is not meeting  the requirement to have these medication double locked.  Before I left each house I had the staff lock the combination boxes.  The boxes were checked and observed  as locked before I left each house.


summary: 748.1107(a) - Child Rights parent contact-Allow contact between a child and his parent whose parental rights have not been terminated

raw_content: It was determined that direct care staff were not allowing children in care to call their caseworkers.

Correction Narrative: A memo was sent to all staff reiterating the above standard and reminding them to allow the  children at any time to call their  caseworkers, casa, ombudsman, or parents at any time.  See digital file.


summary: 748.1103(d) - Informing child of rights-Person being informed must sign statement indicating he read and understands the rights-signed copy filed in child's record

raw_content: One of four child records reviewed did not have a signed copy of the Child's Rights. There were two  unsigned copies of the child's rights in the child records.

Correction Narrative: A signed copy of the child's rights form, signed by the child in care, as well as the case worker. This form was emailed to the inspector.


summary: 748.2203(c)(2) - Medication Error-Document the medication error

raw_content: Medication errors were marked in the records, but the codes and details in the error logs were delayed by 3 days.

Correction Narrative: documentation was sent to me with the new training she is giving to the medication  staff regarding the medication logs that were done incorrectly.  See Digital file


summary: 748.3273(2) - First Aid Kits-Each one must contain adhesive tape

raw_content: There were several things missing in the vans first aid kit, including: scissors, adhesive tape, tweezers, and gloves.

Correction Narrative: The administrator was not there for this inspection and did not know corrections were ever sent.  New kits were purchased with all the correct items. See digital file for probation 8


summary: 748.3365(b)(2) - Bedding-must provide each child with a mattress cover or protector unless mattress is waterproof

raw_content: There were two beds in the gray house that were missing mattress protectors.  These were not vacant beds, so the staff was going to locate mattress protectors.

Correction Narrative: Pictures were sent of the beds that were missing mattress protectors the morning after the inspection.


summary: 748.1335 - Initial Service Plan-Complete the initial service plan within 45 days after admission

raw_content: One of the girl's initial service plan was completed 98 days after she was admitted.  This needs to be done within 45 days, and it should be signed by the treatment team.

Correction Narrative: Detailed  plans on the service plan guidelines for the agency were written out and sent to all administrative staff.  See digital file


summary: 748.1331(a) - Preliminary Service Plan-Complete plan that addresses child's immediate needs within 72 hours of admission

raw_content: The preliminary service plan done for one child was not done in 72 hours-- it was 16 days late.

Correction Narrative: Preliminary service plan guidelines were written out and sent - see digital file  for details.


summary: 748.3365(c)(1) - Bedding-must provide each child with pillow/bed linens appropriate for temperature including pillowcase, top sheet, fitted or bottom sheet

raw_content: One of the girls' beds had two pillows and no pillow cases.  This has become an ongoing problem.


raw_content: In the child's record reviewed the initial  service plan was not completed timely.  The child was placed 6/4/21 and the plan was not completed until 8/3/21.

Standard Number / Description: 748.1335 - Initial Service Plan-Complete the initial service plan within 45 days after admission


raw_content: On the physical site walk-through, there was a bed in the white house had two pillows without cases.

Standard Number / Description: 748.3365(c)(1) - Bedding-must provide each child with pillow/bed linens appropriate for temperature including pillowcase, top sheet, fitted or bottom sheet

Correction Narrative: Along with correcting it while I was there, the staff received a "final blanket warning" for the sheets, pillow cases and bedding.  They are now to be checking after every shift and making notes that all bedding is on every bed.  Individual penalties will be applied if it happens again.


summary: 748.3239(d) - Evacuation-Must document fire and severe weather drills, including date, time, type of drill, and length of time for evacuation/relocation

raw_content: The last fire drill was done in November of 2020, so one would be needed in May 2021.  There were no diaster drills on file.  These also need to be done every 6 months.

Category: Safety and Emergency Practices

Correction Narrative: Staff have anew schedule where they will be assured that drills are occurring as needed. See digital file


summary: 748.3443(a)(1) - Food Preparation-Food items must be covered & stored off the floor

raw_content: There were several containers of juice and chips on the  floor in the food pantry.

Correction Narrative: pictures sent of pantries, and memo sent out to all the houses regarding keeping all foods off the floor.


raw_content: There was no preliminary service plan completed for two children who  were admitted on 6/8/21.

Standard Number / Description: 748.1331(a) - Preliminary Service Plan-Complete plan that addresses child's immediate needs within 72 hours of admission

Correction Narrative: Today during the HM Inspection I observed the two resident's case file and found that both plan had been completed.


summary: 748.151(2) - Operational responsibilities - Operate according to your approved plans, policies, and procedures

raw_content: The policy with ETOD is to have kids in eye or ear shot -and to check on them every 15 minutes or more if it is in their plan.

Correction Narrative: New guidelines were put in the Gray house, and the girls are no longer allowed to have other girls in their rooms.  Only one is allowed in the game room at a time, and staff has to sit in the girls's rooms if they want to be in one another's rooms.


summary: 748.1341(a) - Initial Service Plan-Must give the child's parent(s) at least two weeks advance notice of the meeting

raw_content: One of the two child records read was missing a 14 day notice for a service plan.

Correction Narrative: Ms. Doan and Ms. Dunn have implemented a better checks and balance system so they don't miss the notices or time frames on the girls initial and subsequent treatment plans.


summary: 748.4657(1) - Annual Training-All caregivers must complete 50 hours

raw_content: In  review of the staff records, one staff had a total of 44 annual training hour for 2020.  The operation had corrected the issue at the time of inspection by making the staff make up 6 additional hours of training in Jan 2021.


summary: 748.303(a)(6)(A) - Serious Incident-Report to Licensing no later than 24 hours after becoming aware that child is indicted, charged, or arrested

raw_content: In review of the serious incident reports, there was one report of a child being arrested that was not reported timely.  The incident occurred 5/22/21 and was not reported until 5/24/21.

Correction Narrative:
During my inspection on today I reviewed the following information  that was sent out in a memo to staff on 6/14/21 from the Administrator:

On the incident report, in the section that lists SERIOUS incidents: these are the following incidents that must be reported to the Texas Abuse Hotline (1-800-252-5400 ) and On-Call personnel immediately.

These situations must also be written on an incident report.

Must include what occurred (circle the incident) , when it occurred (write the date and time), where the incident occurred (what area of the house/what house), how the incident occurred (behaviors that took place before the crisis situation/what happened leading up to the situation), who the incident involved (all staff and kids) the result of the situation (what occurred after the incident, ex: child was taken to the hospital and did not return/did return.)

If a restraint occurred, please complete the incident report with restraint form thoroughly. Include the restraint technique used ( low level hold, etc.). Anytime a restraint is used, must notify on call immediately.

All incident reports must be written immediately and turned into the office within 24 hours of the incident occurring.

Please sign and acknowledge that you have read and understood this memo.


facility_name: Rising Star GRO

summary: 748.1437(3) - Discharge/Transfer Documentation-Must include name, address, telephone number, and relationship of person to whom child is discharged

raw_content: One discharge file reviewed did not disclose the required address, telephone number, and relationship of the individual the child was discharged to.

Correction Narrative: An email from the operation's executive account provided a statement recording the following as a corrective action: Rising Stars Treatment Team will ensure all clients discharge summary will include the work address of the responsible party when youth is discharged. We also have updated the Rising Star Summary Discharge form to include all required fields. Please see the attached form. The administrator will check for compliance.


summary: 748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records

raw_content:
While reviewing 1/3 children's admission record, there is conflicting information regarding dates. Some documents record date of admission as 12/04/2024 other documents record date of admission as 12/05/2024.
While reviewing 1/3 children service plan, a signed copy by another child was found in the wrong placement.

Correction Narrative: An email from the operation's executive account provided a statement recording the following as a corrective action: This was an typo on the youth face sheet all other documents dates matched the actual admission of the youth in care. Rising Star Treatment Team will audit all documentation to make sure to catch typos and that all information and dates match as they should. The administrator will check for compliance.


summary: 748.1205(a)(1) - Admission Documentation-Includes child's name, gender, race, religion, date of birth

raw_content: While reviewing the children's files. 2/3 were missing the children's religion preference.

Correction Narrative: An email from the operation's executive account provided a statement recording the following as a corrective action: Rising Stars Treatment Team will ensure all youth religion is documents on the admission assessment and the 72 hours assessments. When not known and the youth does not know we will enter unknowns. The administrator will check for compliance.


summary: 748.1207(a)(3) - Placement agreement-Must include the reason for placement & anticipated length of time in care

raw_content: One child's record reviewed did not contain the anticipated length of stay.

Correction Narrative: An email from the operation's executive account provided a statement recording the following as a corrective action: Rising Stars Intake Team will ensure all youth Placement Agreement have all the required information documented. This information is also displayed on the Admission Assessments which is completed before arrival. The administrator will check for compliance.


summary: 748.685(c)(6) - Implement and follow the children's service plans.

raw_content: Operation is not following service plan for child in care related to supervision.

Correction Narrative: Agency emailed corrective action to licensing representative on 02/12/2025.


summary: 748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being

raw_content: Two residents, one with a history of AWOL, were allowed to go to the park without staff attendance.

Correction Narrative: This follow up was completed by inspection. Please refer to inspection 3994754. The operation will ensure to follow the service plan supervision requirements when allowing children to engage in outdoor activities. During the inspection the children were interviewed, and they confirmed required supervision was being followed.


raw_content: Two preliminary service plans were found to be missing supervision requirements for the children while inside the facility.

Correction Narrative: This follow up was completed by inspection. Please refer to inspection 3994754. The operation completed the supervision sections for the incomplete service plans that were identified. The operation put a plan in place to ensure all documents were thoroughly completed in a timely manner.


raw_content: During a review of the records I found 2 records missing needed discharge information including; where the children were being released to, documention of service plans for the last 12 months and progress notes; and the reason for discharge.

Standard Number / Description: 748.1437(3) - Discharge/Transfer Documentation-Must include name, address, telephone number, and relationship of person to whom child is discharged

Correction Narrative: RCCL Inspector received the following information from Management staff: Rising Star GRO will make sure that all Discharge Documentation will include all requested information in regards to the location of the next placement if provided by the caseworker and if not, we will note that the information was requested but not given and attach the email to paperwork. Discharge documentation will be reviewed by the Case Manager and the LCCA to make sure all areas are covered in its entirety.


summary: 748.151(4) - Operational responsibilities - Allow Licensing to inspect the operation during its hours of operation

raw_content: Licensing arrived at the operation at 9:30a. There was no one at the operation to let the licensing representative in until 10:13a.

Correction Narrative: RCCL Inspector received an email that the operation will ensure that a team member is here during operations hours


summary: 748.2151(d) - Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model

raw_content: 3 of the child's files observed did not have accurate counts of the medicine that was given.

Correction Narrative: RCCL Inspector Received an email that the operation has created Audit Form and Refill Log as a method for tracking medications. The administration team will check medications daily and will have frequently MARS trainings.


summary: 748.2151(c)(5) - Medication record - must include date (day/month/year) & time each medication was administered

raw_content: 4 of the child's files observed did not have the time that the medication was administered.


facility_name: Pathways 3H Youth Ranch

summary: 748.3113(c) - Fire Extinguisher-Fire extinguisher that has been used or has lost operating pressure must be serviced or replaced immediately with equivalent unit

raw_content: Two fre extinguishers in the cabins did not have operating pressure.

Correction Narrative: Firec extiguishers have been replaced and are in working order.


summary: 748.3233(b)(3) - Evacuation-Emergency evacuation & relocation diagram must include designated location inside operation to take shelter from threatening weather

raw_content: Posted evacuation plans did not have required gathering information for severe weather.

Correction Narrative: Posted evacuation plans have the gathering place added to them.


summary: 748.3441(m) - Food Preparation-Food must be thawed in the refrigerator, in cold water in a leak-proof bag, or in the microwave

raw_content: Food was being thawed in the kitchen sink of the cafeteria.

Correction Narrative: Food will no longer be thawed in the kitchen sink and coaching was given to staff.


summary: 748.1661(b) - Tobacco Products-Adult may not smoke tobacco products, e-cigarettes, or vaporizers in children's living areas/inside any building on premises w/ kids

raw_content: Staff was smoking a nicotine vape pen on campus in staff restroom.

Correction Narrative: Operation repsonse recieved: Staff member admitted to the vaping and was written up for violating minimum standard as well as company policy. In addition staff have received Child's Rights Trainings on various dates since the incident. A copy of the write up as well as a roster of attendees for trainings will be maintained and can be provided upon request


summary: 748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks

raw_content: It was confirmed by staff and children that some staff will get in children's faces and speak to them in a way that will instigate or anger them. It was also confirmed that staff will use curse words in the presence of children.

Correction Narrative:
Operation has come in to complaince with the following while lineups are not used as punishments, we will provide additional clarification to all staff that lineup times should not exceed a few minutes and should only.
be used to restore order and facilitate transitions. This training will be completed by the end of May, 2025.


summary: 748.2307(8) - Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child

raw_content: It was confirmed by staff and children that some staff will yell in a child's face to make them comply.

Correction Narrative:
Operation has come in to complaince by an all-staff meeting on 4/2/2025, staff received training on maintaining
appropriate language around residents at all times and refraining from using profanity in the presence of children.


summary: 748.2455(a)(2) - Emergency Behavior Intervention-Basis for EBI is an emergency situation or to administer medication

raw_content: It was confirmed by staff and children that EBI has been used for situations that are not an emergency. It was confirmed that staff have used EBI on children because they are walking away from staff or not complying with staff direction.


summary: 748.2551(c)(2) - EBI Implementation-Caregiver must use the minimal amount of reasonable and necessary physical force

raw_content: It was confirmed by staff and children that staff will use excessive force while implementing EBI restraints. Children state that staff will grab their arms with enough force that it causes them pain.

Correction Narrative:
Operation has come in to complaince by In an all-staff meeting on 4/2/2025, staff received training on maintaining
appropriate language around residents at all times and refraining from using profanity in the presence of children.


summary: 748.2461(a)(1) - Short Personal Restraint-Caregiver must minimize risk of physical discomfort, harm, or pain to child

raw_content: Child was not following staff directives and was put into a short personal restraint. While doing so the child put their weight down and the staff released the child causing the child to fall. Child sustained a right distal radius fracture as a result.

Correction Narrative:
Follow up conducted on 08/12/24 inspection ID#4014485- an interview was conducted with the administrator to explain the trainings that are being conducted:
Operation sent in corrective plan on 07/30/24:

Due to citation and technical assistance given to Pathways 3H Youth Ranch during investigation regarding standard 748.2461 (a)(1) Short personal restraint caregiver must minimize risk of physical discomfort, harm, or pain to child.

The following trainings will be provided to all Pathways 3H Youth Ranch Direct Support Professionals.

Emergency behavior intervention 4 hours with a focus on decision making, physical control dynamics, minimum standards EBI, and processing with children to build rapport.

Understanding the needs of children 2 hours-based diagnosis and development levels.

The trainings will begin August 6, 2024 and continue through August 14, 2024.


summary: 748.3235 - Evacuation-Must post the emergency evacuation & relocation diagram in a prominent/visible location in all buildings

raw_content: Evacuation plan must be posted in all buildings. The recreation room was missing one.


raw_content: Caregiver did not use proper EBI method, child in care was pulled inappropriately this was confirmed by other residents in care.

Correction Narrative: Follow up conducted MSR found to be compliant


summary: 748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language

raw_content: Four children in care indicated a staff member uses profane language with the children in care. A second staff member indicated profane language just slips out sometimes. The staff member who allegedly uses profane language claims to have not done so since being investigated by Licensing (Spring 2021), however three of the four children in care claiming profane language usage were admitted to the operation after Spring 2021 and the staff who admitted there's profane language her was hired in Spring 2022.

Correction Narrative:
This response is in reference corrective action taken concerning investigation.
Specifics: Four children in care indicated a staff member uses profane language with the children in care. A second staff member indicated profane language just slips out sometimes. The staff member who allegedly uses profane language claims to have not done so since being investigated, however three of the four children in care claiming profane language usage were admitted tp the operation after spring 2021 and the staff who admitted there's profane language was hired in spring of 2022. Action taken: Staff that allegedly uses profane language has since resigned from employment at Pathways 3H.
Additional training on inappropriate language has been provided to the staff hired in the spring of 2022. Additional training is being provided to Pathways 3H Youth Ranch direct care team. All Direct Care Support will complete by 08/17/22.


raw_content: Staff should not use EBI for getting a child to comply with them.

Standard Number / Description: 748.2455(a)(2) - Emergency Behavior Intervention-Basis for EBI is an emergency situation or to administer medication

Correction Narrative:
This response is in reference corrective action concerning investigation #2892382. Standard Rule 748.1101(b)(1)(B) Childrens Rights to be free of abuse,neglect, and exploitation. Specifics A child in care was restrained and injured as a result. Standard/Rule 748.2455(a)(1) EBI Before using EBI the caregiver must attempt less restrictive interventions that prove to be ineffective. Specifics: Staff use less restrictive methods first before attempting EBI. Standard Rule 748.2455(a)(2) EBI-Basis for EBI is an emergency situation or to administer medication. Specifics-Staff should not use EBI for getting to comply with them. Action Taken: Staff involved was placed on administrative leave pending results of the investigation and has since then resigned from Pathways 3H Youth Ranch. Pathways has requested an administrative review through our attorney on all of the deficiencies related  to this.  investigation.
  09/28/22 Face to face with Shawn Flores Director to go over follow up plan for deficiencies. He stated they are going to have treatment director to TBR monthly. They will have all staff attend. They are going to upgrade their camera system. We will have monthly EBI break downs and Shawn will be in charge of conducting those. One unit out of the ten units covers it. They will have different methods they go over before EBI implemented. Preventative techniques. They are trying to implement a youth leadership board to give insight on services and programs. They have a compliance team for all of Pathways and they review all over program and over documentation and collect data. They then ask how they want up to compile data and we let them know. The data can be focused all on EBI and help staff know what is going on. For example if they collect at the beginning of the week and see less restraints  done then they can see what they are doing to help make that change.


summary: 748.2307(1) - Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment

raw_content: Child confirmed staff held child around the neck.

Correction Narrative:
Letter received from operation that:
Standard rule 748.2307 ( 5) Other prohibited punishment maintaining uncomfortable position

Deficiency: it was confirmed through interviews that a child was made to feel unsafe in a restraint. Those interviewed described the restraint as a hold around the neck of the child.

Action Taken: Staff involved has submitted voluntary resignation of employment from Pathways 3 H Ranch.


raw_content: A staff member  pushed and yelled at a child in care.

Standard Number / Description: 748.2307(1) - Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment

Correction Narrative: The operation responded to the deficiency stating that the staff involved in the incident was terminated from employment. The operation will be providing staff with additional training on EBI to include crisis development, non-verbal and verbal intervention and control dynamics. The training will be completed by March 15, 2022.


summary: 748.935(a)(2) - Annual Training Timeline-Each person must complete the required annual training during each subsequent 12-month period

raw_content: The normalcy training and trauma informed care training found in the employee file were over two months late.

Correction Narrative: Annual training dates have been entered into a new (Relias) training and tracking database. The database has been set to send email reminders to the staff and trainer 30 days prior to trainings expiration.


summary: 748.931(a)(2)(B)(iii) - Annual Training-Every 6 months a caregiver must complete at least 4 hours of training in EBI

raw_content: One staff did not receive their emergency behavior training within the 180-day timeframe.

Correction Narrative:
Facility sent email with plan of compliance.
This response is in reference to a heightened monitoring inspection on September 14, 2021.

Deficiency:  748.4657(1)(A) Annual training every 6 months a caregiver must complete at least 4 hours of training in EBI.

Specifics: One staff did not receive their emergency behavior training within the 180 day timeframe.

Action taken: The staff referred to received their training four past 180 days timeframe. All EBI training dates have been entered. into a new training and tracking database. The database has been set to send email reminders to the staff   and trainer 30 days prior to the trainings expiration.

Technical assistance: Standard/Rule 748.3365 Bedding must provide each child with a mattress cover or protector unless mattress is waterproof.

Specifics: It is best practice to ensure all mattress protective covers are places on children's beds to prevent the mattress from becoming soiled by the children sleeping on them.
Action Taken: Upon further review by the Program manager on the day of the inspection it was discovered that the mattress covers were in place buy may have been pulled back with the fitted sheets. Mattress covers are checked at least weekly during the Physical Site Inspection and documented on the physical site inspection form.


raw_content: It was found that EBI training was incomplete for 2 staff post-6 months from the last training.

Standard Number / Description: 748.931(a)(2)(B)(iii) - Annual Training-Every 6 months a caregiver must complete at least 4 hours of training in EBI

Correction Narrative: Provided documents by Administrator Joel Grimmett affirm training was completed in an adequate and timely manner. The required training certificates were misplaced during initial inspection.


raw_content: Multiple children in care indicated care givers at the operation use profane language with the children in care and had details about what words were said and it how it made the children in care feel. Multiple staff admitted to using profane language in the presence of children in care.

Standard Number / Description: 748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language

Correction Narrative:
Email from operation regarding citation for 748.2307 (9) Other prohibited punishment subjecting child to profane language .

Action taken: Staff have been received additional training on Pathways 3H Youth Ranch Policy and Minimum standards for GRO on inappropriate language.
A copy of policy, standards and training agendas for the staff are attached.

Although we have chosen to immediately address the use of profanity at the facility, we do not feel that it was used as punishment and intend to file administrative review.


facility_name: Harmony Therapy and Treatment Center LLC

raw_content: The posted evacuation plan did not specify an indoor meeting place.

Standard Number / Description: 748.3233(b)(3) - Evacuation-Emergency evacuation & relocation diagram must include designated location inside operation to take shelter from threatening weather

Correction Narrative: An email was received with the corrective action being The diagram was posted on the wall under the fire extinguisher.


summary: 748.303(a)(6)(A) - Serious Incident-Report to Licensing no later than 24 hours after becoming aware that child is indicted, charged, or arrested or when police respond.

raw_content: A youth in care was arrested on 09/09/2025 and the operation did not report this incident to licensing.

Correction Narrative:
An email was sent for the corrective action Corrective Action Taken: All administrative and direct care staff will be retrained on Serious Incident Reporting requirements by November 11, 2025.
Preventive Measure: Serious incidents will be reported to Licensing within 24 hours of awareness. The Program Director will review all incident reports daily for compliance.