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: It was found that a staff was not inactivated within 7 days of no longer being associated with the operation.


state: TX

facility_name: Adullam Homes, LLC

summary: 748.3365(b)(1) - Bedding-must provide each child with a clean and comfortable mattress

raw_content: It was found that a child's bed had a mattress foam topper instead of a mattress.

Category: Individual Standards Evaluated

Standard Risk Level: Medium

Corrected at Inspection: Yes


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

raw_content: It was found that staff were active that are no longer employed on the staffing list.

Category: Organization and Administration

Corrected at Inspection: No

Correction Narrative: The operation sent the following documentation by email The administrator/HR will do a random check on background checks to make sure that staff or mark inactive per minimal standards.


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

raw_content: It was found that there was rodent dropping in the cabinet of the kitchen.

Standard Risk Level: Medium High


summary: 748.1331(c) - Preliminary Service Plan-Must be compatible with the information in the  admission assessment

raw_content: Three children's preliminary service plans lacked specific supervision requirements and did not take into account the high-risk behaviors noted in their admission's assessment.

Standard Risk Level: Medium Low

Correction Narrative:
The operation stated:
The administrator, Treatment director, and case manager will review all services prior to writing an admission assessment or 72hr service plan to make sure that it matches what is needed for each individual resident.


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

raw_content: Children with high-risk behaviors such as of AWOL, car theft, and physical aggression were allowed time to walk around in Walmart, unsupervised, and stole alcoholic beverages.

Standard Risk Level: High

Correction Narrative:
A physical follow up was conducted on 4/30/24, the only child in care was interviewed with no concerns noted.
The operation's corrections stated:
2.	The administrator and treatment team, prior to excepting a youth that need additional supervision will have a thorough meeting before admitting a youth. Staff will have a refresher training on proper supervision to adhere to the minimal standards so that youth in care can be safe. The training was completed on 4/29/24, led by Damian Newton. Attendees included LEON ATLAS, NIKEALA JONES, ARIANNA MCCOY, and TAMEKA JONES.


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

raw_content: The administrator's license expired on 12/12/23 and his a renewal packet has not been submitted as of 12/27/23.

Correction Narrative: The administrator's renewal packet was received by licensing on 1/2/24.  This brings this standard back into compliance.


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 a review of external documentation, there was no indication of the completion of a safety plan for a child with identified high risk behaviors addressed in the child's admission assessment.

Correction Narrative: I, RCCL Inspector Michonne Chandler received an email from the administrator Damien Newton stating the following: Future placement will be discussed between the administrator and treatment director. If a safety plan is needed it will be documented and signed by the case manager, case worker, staff and administrator. Therefore, everyone will be prepared for any type of AWOLS or Behavioral issues at Adullam Homes.


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: A staff member threatened children in care.

Correction Narrative: I, RCCL Inspector Michonne Chandler received an email with a document from the administrator Damien Newton stating the following: The administrator will provide TBRI/EBI training for staff so that staff understand different LOC and proper way to support youth in critical moments per minimal standards.


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

raw_content: It was found in a bedroom that there was water damage on the ceiling. The operation did not have a corresponding work order to address the ceiling concern.

Correction Narrative: The operation sent an email stating that the Administrator will complete timely work orders and will report all damages to the operation owner and maintenance so that the repairs can be done in a reasonable time.


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

raw_content: It was found in 2 out of 2 children's active files reviewed that the time of the administration of medication was missing.

Category: Medication


summary: 748.753(a)(1) - Pre-Employment Screening-You must complete reference checks by obtaining the name and contact info of two individuals who can serve as references.

raw_content: It was found that the operation did not contact any applicants refernce check.

Category: Personnel

Correction Narrative:
The operation sent an email stating that the following will be done:1.ADULLAMSHOMES GRO will conduct a reference check once the background check has been cleared for employment. All staff will be informed that a reference check is necessary per minimal standard.
2.The Administrator and Humann Resource will be conducting the reference check and will document on the form provide by DFPS.


summary: 748.3301(c) - Physical Site-Windows & doors must be in good repair & free of broken glass or hazards

raw_content: During walk through of operation it was noted that the window in bedroom 2 was broken

Category: Physical Site

Correction Narrative:
inspection #3965055

all corrections are located in document library showing the correction made.


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

raw_content: Upon review of CLASS administrator is working for two operations


summary: 748.3301(f) - Physical Site-The grounds of the operation must be well maintained and free of hazards

raw_content: It was found that the fence was in mal repair with an open space into the neighbor's backyard and.


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: upon review of LCCA file drug test was not located


facility_name: True Home of Hope Inc

summary: 748.509 - TB screening-Caregivers, employees, volunteers, contract service providers screened for TB before having contact with children in care

raw_content: Staffs files are missing documentation of a TB screening.

Correction Narrative:
As a resolution the operation advised that all affected staff have received TB screenings, and documentation is now present in their personnel files as of 06/30/2025.
As preventive measures they advised that they have implemented a policy requiring TB screening results before staff may have contact with any child. They have updated onboarding checklist to include TB screening as a pre-employment requirement full compliance has been achieved and ongoing enforcement starting immediately. The case manager and LCCA must track TB screening results and verify that the staff is cleared for child contact. Will maintain audit-ready files. Staff without TB documentation will be removed from direct care duties until documentation is obtained.


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 files are missing the summary of the reference check interviews.

Correction Narrative:
As a resolution the operation advised that Missing reference summaries have been documented and added to the applicable staff files as of 06/30/2025.
As preventative measures the operation emailed advising that the Reference Check Summary Form were completed to ensure consistent documentation. Staff conducting reference checks must complete this form and submit it to HR prior to final hiring approval. All new hires' effective date will follow this protocol. The case manager or LCCA is responsible for ensuring that the summary form is completed for each reference and that it is reviewed before hiring decisions are finalized.


summary: 748.363(8) - Personnel records - Include a Pre-Employment Affidavit for Applicants for Employment as specified in Texas Human Resources Code §42.0563

raw_content: An employees file is missing a A Pre-Employment Affidavit form.

Category: Reports and Record Keeping

Correction Narrative:
As a resolution the operation advised that the missing Pre-Employment Affidavit (Form 2912) has been obtained and placed in the employee's personnel file as of 06/30/2025.
The operation emailed CCR advising that as preventive measures they will Revise the employee onboarding checklist to include mandatory completion of the Pre-Employment Affidavit before the start date. The Administrative staff will not permit onboarding without receipt and verification of this affidavit. The case Manager and LCCA will verify the affidavit's presence before the employee starts work and conduct quarterly file audits. Staff responsible will be re-trained and subject to progressive disciplinary action.


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

raw_content: Four youth in care stated staff members use profane language.

Correction Narrative:
To maintain a professional and respectful environment, all staff were reminded of conduct expectations.

Preventive Measures:
	Reinforced policy on appropriate language during team meetings.
	Mandatory refresher on respectful communication included in staff training.
	Immediate reinforcement completed and preventive measures put in place on 06/25/2025.
	The Facility Administrator, program director, and case manager will conduct unannounced shift visits and interview youth for ongoing feedback.
	Any verified instance of profane language will result in progressive disciplinary action up to termination.
	Case Managers will document and report concerns during clinical team reviews. They will also educate youth on their right to report inappropriate behavior confidentially.

No follow-up inspection is required due to operation has been on placement hold with DFPS effective 06/02/25.


raw_content: Three youth in care reported witnessing staff member push youth in care.

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

Correction Narrative:
	Ongoing training and refreshers on trauma-informed care and prohibited practices.
	All staff reaffirmed understanding of the "no physical discipline and reviewed of policy with staff members.
	Continued use of surveillance monitoring and incident reporting procedures to ensure transparency and accountability.
	Procedures are reinforced and ongoing training.
	The Program Director and Training Coordinator will ensure all staff remain in compliance.
	Supervisors will continue random shift observations.
	Any future confirmed physical contact that violates policy will result in immediate
	administrative leave and investigation. Non-compliance with training requirements will trigger disciplinary action.
	Case Managers will continue biweekly check-ins with youth to assess safety and well-being and immediately report any concerns for review.

No follow-up inspection is required due to operation has been on placement hold with DFPS effective 06/02/25.


summary: 748.531(a)(3) - Child-care administrator-Is full-time employee of the operation

raw_content: None of the children reported having met the individual listed as the facility's administrator. Additionally, the staff member was unable to provide the administrator's name or contact information.

Correction Narrative:
The administrator continues to maintain daily on-site presence.
Administrator availability is logged and visible in the facility's daily records.
Staff are reminded regularly of the internal leadership structure.
The facility remains fully compliant with administrator availability standards.


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

raw_content: A staff member was observed engaging in a verbal confrontation with a resident requiring intervention from licensing rep.

Correction Narrative:
	Staff were informed to maintain calm redirection techniques at all times.
	Leadership emphasized that licensing staff interactions with facility personnel should be conducted privately to avoid disrupting behavior interventions or compromising the care staff provide.
	Facility continues to monitor staff-resident interactions to ensure therapeutic communication practices are followed.
True Home of Hope prioritizes professionalism, de-escalation, and therapeutic safety in all resident interactions.

No follow-up inspection was needed as all children in care have been removed as of 6/2/25.
The operation is currently on Placement Hold with DFPS.


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

raw_content: A child in care left the facility without staff's knowledge. Licensing rep had to notify the staff of the incident who then went looking for the child during the visit. Another child left the facility because she wanted to attend church but no one was available to transort the child. Staff did not follow the child as required.

Correction Narrative:
Staff have been reminded of response expectations during transitional moments (e.g., scheduled outings or activities, any delays).
Staff-to-child ratio has been strengthened to 23 children per staff, exceeding minimum standards as usual at True Home of Hope.
Ongoing refresher training is conducted on redirection and elopement response protocol.
True Home of Hope remains committed to maintaining supervision and safety for every child at all times.

No follow-up inspection was needed as all children in care were removed as of 6/2/25.
The operation is currently on Placement Hold with DFPS.


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

raw_content: One of the residents did not receive one of her AM medications due to medication ran out according to staff.

Correction Narrative:
Staff were informed to clearly document medication changes in real time.

Pharmacy inventory logs were updated to reflect dosage adjustments.
Medication disposal protocol was reaffirmed with staff.

No follow-up inspection was needed as all children in care have been removed as of 6/2/25.
The operation is currently on Placement Hold with DFPS.


summary: 748.1003(a) - Child/caregiver ratio-Caregiver may care for 5 children if any require tx svcs, 8 children if not; children under 5 yrs old count as 2 children

raw_content: One of the children was on 1:1 supervision due to high risk behaviors; however, during the licensing visit, a staff member was observed supervising five residents for approximately 30 minutes before a second staff member arrived. A staff member left to pick up a child at the hospital during the visit lieaving one staff member with the 5 residents, one of which was on 1-1 supervision.

Correction Narrative:
	Supervision plans for all youth have been reviewed to ensure documentation accuracy.
	Facility has confirmed that supervision ratios continue to exceed minimum requirements.
	Staff scheduling procedures include safeguards to avoid lapses during transports.
True Home of Hope continues to operate in full compliance with staffing ratios and supervision protocols.

No follow-up inspection was needed due to all children in care have been removed as of 6/2/25.
The operation is currently on Placement Hold with DFPS.


summary: 748.535(3)(A) - Child-care administrator responsibilities-Overseeing staffing patterns to ensure supervision and child-care services meet the needs of children

raw_content: A child in care left the facility alone during licensing visit to attend church because staff was not available to transport the child. Due to staffing shortage, no staff followed the child when she left the facility.


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 agency has not submitted their EBI data for the 1st quarter of 2025.

Correction Narrative:
True Home of Hope staff members have compile and submit the missing EBI data by April 16, 2025.
Responsible staff will receive refresher training on EBI reporting requirements by a due date.
A monthly compliance checklist will be implemented by the destinated staff.


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 medication counts were not accurate in 2 of the reviewed medication logs.

Correction Narrative: This standard was reviewed and found to be in compliance.


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: Medication logs were reviewed to be incomplete and not updated timely.

Correction Narrative:
The operation currently does not have any children in care. The operations advised of the following as corrections:
The Medication Administration Log (MAR) was updated to include a mandatory double-verification checkbox before each administration. 7/22/2025
Staff were re-educated on the requirement to document medication administration within 2 hours and ensure cumulative logs are complete and up to date.
Documentation of corrective action training will be placed in the personnel file.
Program Director will monitor audit results and initiate performance improvement plans for noncompliant staff.
Case Managers will review each child's medication record weekly to confirm that administration and documentation match the physician's order.
The facility will conduct quarterly policy reviews, which will be used to reinforce standards and address emerging gaps.


raw_content: A child in care was prescribed medication that was not administered to the child.

Standard Number / Description: 748.2003(b)(5) - Administration of prescription medication-Ensure the child has taken the medication as prescribed

Correction Narrative:
The operation currently does not have any children in care. The operations advised of the following as corrections:
All staff received refresher training on medication administration policy on 7/22/2025, emphasizing the 5 Rights of medication (right child, right drug, right dose, right time, right route).
A daily end-of-shift medication must be implemented to ensure no prescribed medication is missed.
The supervisor must cross-reference physician orders with MAR logs for new orders and weekly.
The supervisor and case manager will ensure every dose is accounted for and documented within 2 hours of administration.
Any missed or skipped doses must be immediately escalated to the LCCA or Program Director and addressed according to the minimum standards.
Continued noncompliance will result in disciplinary action, up to and including suspension from direct care responsibilities.


raw_content: During the inspection it was found that medication counts were not accurate.

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


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 there was no record of administering 3 medications.

Correction Narrative: This standard was evaluated and found to be in compliance.


summary: 748.2003(b)(4) - Administration of prescription medication-Administer each child's medication within one hour of preparation

raw_content: During the inspection it was observed that PM medications were being prepared in the AM hours by being removed from the package and placed in a container.


summary: 748.505(b)(4) - Minimum qualifications for employees-Complete notarized Licensing Affidavit for Applicants for Employment form

raw_content: One employee's file did not have a completed notarized affidavit.


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: There are no personal towel, single use disposable towels, or hot air hand dryers in the upstairs bathroom.

Correction Narrative: Bathroom did have paper towels for hand washing.


raw_content: Upon moving out of the operation, staff refused to give a child's MP3 player and cell phone back due to the child and case worker not allowing staff to search her belongings.

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:
Children have the right to retain personal items unless those items pose a risk to safety.

Upon admission, an inventory of personal belongings will be taken and stored in the child's file.

If a child moves out of the facility, all belongings must be returned unless prohibited by law or caseworker directive.

Staff cannot withhold personal belongings as a form of discipline or due to refusal of a search.


summary: 748.1117 - Documentation of searches-Caregiver documents searches in the child's record

raw_content: There was no documentation provided for searches completed of the children's belonging by the staff.

Correction Narrative:
Searches will only be conducted when there is reasonable suspicion of contraband, safety concerns, or per the facility's routine search schedule.

All searches must be documented using the Resident Belongings Search Documentation Form and reviewed by a supervisor.

The least intrusive method of searching should always be used.

The child should be present during the search unless it is deemed unsafe.

Any items confiscated must be documented, stored securely, and handled according to facility procedures.


summary: 748.453(a)(2) - Unauthorized Absence - Annual summary log must include time and date absence was discovered

raw_content: The unauthorized log provided does not contain full record of all unauthorized absences of children in care.

Correction Narrative:
1.Documentation:

All unauthorize absences will include the required components (duration of absence, intake report number, law enforcement agency name and report number, etc.).

A revised and comprehensive unauthorize absence log will be created, ensuring that all required fields are clearly defined and incorporated.

2.Training and Education for Staff:

All staff involved in documentation undergo training on the updated policy and procedure for maintaining unauthorized absence logs. This will include:
	-How to properly document the length of time a child is absent.
	-The importance of recording the intake report number for hotline incidents.
	-How to correctly record the law enforcement agency's name and report number when applicable.
	The requirement to allow all unauthorized absences, ensuring no incident- is omitted.

A staff member from the management team will be designated to review the log entries to ensure accuracy and compliance.


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

Correction Narrative: During the inspection it was found that the operation did not have a record of administering a child's afternoon medication. - This will be a citation on the Inspection completed on 4/7/25.


Correction Narrative: During the inspection it was found that the operation did not have accurate daily counts of each child's prescribed medications - This will cited on Inspection completed 4/7/25


summary: 748.535(1) - Child-care administrator responsibilities-Daily supervision and on-site administrative responsibility for the overall operation

raw_content: During the inspection it was found that the operation's administrator confirmed that they are present for less than what is defined as full time hours.

Correction Narrative: The administrators time log was observed and indicated the adminstrator is present full time hours.


Standard Number / Description: 748.2151(b)(1) - Medication record - update cumulative record within 2 hours of administering medication

Correction Narrative: During the inspection it was found that the operation did not update the medication record timely. The medication records were missing signatures and times prescription was given. - This will be a citation on Inspection conducted on 4/7/25.


summary: 748.2003(b)(10) - Administration of prescription medication-must not borrow or administer prescription medication to a child that is prescribed to another person

raw_content: During the inspection it was found that the operation administered a medication to a child that prescribed to another child.

Correction Narrative: Medication is labeled and separated into each child's individual lock box.


summary: 748.2101(6) - Medication storage & destruction-remove discontinued medication immediately & destroy it in a way that ensures children do not have access to it

raw_content: During the inspection it was found that the operation did not store a child's discontinued medication separately from current medications

Correction Narrative: Only current medications were observed in the child's medication lock box.


summary: 748.2151(c)(3) - Medication record - must include reason medication was prescribed, for prescription medication

raw_content: During the inspection it was found that the operations medication records did not include the reason the medication was prescribed

Correction Narrative: The medication records include reason the medication is prescribed.


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

raw_content: A staff file requested was not available for immediate review.

Correction Narrative: Files were available for review upon request.


summary: 748.455(a) - Unauthorized Absence-After a child returns from unauthorized absence, foster parent must conduct debriefing w/child no later than 24 hrs after return

raw_content: Not all of the debriefings were completed or documented that an attempt was made.

Correction Narrative: The facility created a debriefing form which will be used after all significant incidents. Ttraining curriculum was observed to include the topic of conducting a debriefing after a child has an unauthorized absence.


summary: 748.303(a)(10)(B) - Serious Incident-Report to parents no later than 6 hours after determining unauthorized absence of a child 13 years old or older.

raw_content: Notifications are not being made to the caseworkers when a child over the age of 13 has been on an unauthorized absence longer than 6 hours.

Correction Narrative: The operation submitted the following correction: The facility will implement notifying caseworkers or parents within the required timeframe when a child over the age of 13 has been absent/Serious Incident-Report for more than 6 hours without authorization.	All relevant staff members will receive training on the updated procedure for managing unauthorized absences or Serious Incident-Report and the importance of timely notifications to caseworkers or parents. A follow up was conducted by inspection (INSP ID: 4043477) and the training curriculum was observed.


summary: 748.453(a)(3) - Unauthorized Absence - Annual summary log must include how long the child was gone or if the child did not return

raw_content: The unauthorized absence log does not include all of the required components such as how long the child was gone fore, intake report number for the incidents that were reported to the hotline, or the name of LE agency & number of police report. In addition, it does not indicate all unauthorized absences that have occurred at the operation.

Correction Narrative:
The operation provided the following correction: A revised and comprehensive unauthorize absence log will be created, ensuring that all required fields are clearly defined and incorporated. All staff involved in documentation undergo training on the updated policy and procedure for maintaining unauthorized absence logs. A staff member from the management team will be designated to review the log entries to ensure accuracy and compliance.
A follow up was conducted by inspection (INSP ID: 4043477) and the unauthorized absence log was observed.


summary: 748.863(b) - Caregivers who have not completed all pre-service training may not be counted in ratio unless there is a qualified caregiver counted at same time.

raw_content: A staff member who was not fully trained was left alone at the operation with 3 children, 2 of which had a history of habitually running away from the operation and resulted in 2 of the children running away.

Correction Narrative: The operation provided the following correction: The facility will implement a policy that prohibits leaving any untrained or insufficiently trained staff member alone with children, especially in situations involving children with known safety risks, such as running away. A review of all staff qualifications and training will be conducted to ensure that every staff member is fully trained in child supervision and emergency response before they are left alone with children. A follow up was conducted by inspection (INSP ID: 4043477) and the training rosters were observed.


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

raw_content: The serious incident was documented but was missing information, such as name of operation, physical address, telephone number.  Also missing is the child's name, age, gender, and date of admission of the child.

Correction Narrative: Email received on 1/21/2025 from operation stating that their Serious Incident Report form has been updated to reflect the current requirements of minimum standards. Training was conducted for all staff to ensure they understand the updated SIR form and its proper use.  Training covers the purpose of the form, how to accurately complete it and the reporting timeline.


summary: 748.3101(2) - Fire Inspection-Must have fire inspection at least once every 12 months from date of last fire inspection

raw_content: Both fire extingushers have not been serviced for this year.

Correction Narrative: This standard was evaluated and found to be in compliance.


summary: 748.3115(1) - Fire Extinguisher-Must ensure there will be no interference with access to the extinguisher in an emergency

raw_content: The upstairs fire extinguisher was behind a locked closet.  This was corrected at inspection.


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

raw_content: The childs preliminary service plan does not address their supervision needs.

Correction Narrative: On 8/24/2024, Executive Director emailed the compliance plan. As a result, True Home of Hope Inc will ensure comprehensive assessments for child placement and ongoing evaluations. Responsibilities include organizing medical and psychological appointments, issuing monthly reports, and managing admission and discharge summaries. Additionally, develop service plans tailored to address the child's supervision and treatment needs. All team members are required to review and sign the Initial Service Plan within 15 days. The Program Administrator is responsible for enforcing all minimum standards consistently and ensuring the availability of all reports and records for Licensing staff review.


summary: 748.685(a)(3) - Caregiver responsibility - being aware of and accountable for each child's on-going activity

raw_content: A child in care engaged in substance and alcohol abuse around the community during repeated elopements from the operation.


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

raw_content: Staff used inappropriate language towards and in the presence of the residents.

Correction Narrative: Staff and child interviews were conducted and innapropriate languiage is not being used towards the children or in the prescense of the children.


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: During a review of documentation, the operation had no record of routine fire drills.

Category: Safety and Emergency Practices

Correction Narrative:
True Home of Hope will schedule an emergency meeting to address the importance of fire drill records and discuss the importance of emergency preparedness. Will initiate an immediate review of existing emergency response according to the minimal standard to identify any other deficiencies.
True home of hope will establish a schedule for regular severe weather drills to be conducted Monthly and quarterly, with a drill that was scheduled on 05/05/2024.
A clearly define the type of severe weather scenarios to be simulated during drills (e.g., tornado, hurricane).
A specify length of time allocated for evacuation or relocation procedures during drills, ensuring realistic and achievable targets.
The designate evacuation routes and assembly points for everyone to gather safely following evacuation.
Appointing trained personnel to oversee the execution of drills and ensure compliance with minimal standards.
Document the date, time, type of drill, and outcomes of each severe weather drill for future reference and evaluation.
Training and Awareness:
True home of Hope will provide comprehensive training sessions for everyone on severe weather preparedness, including evacuation procedures and the importance of compliance during drills.


summary: 748.4003(1)(B) - General requirements-When transporting a child the operation must ensure each driver is covered by automobile insurance

raw_content: During a review of documentation, the operation was unable to provide an updated insurance card as for it expired on 4/23/2024.

Category: Transportation

Correction Narrative: True Home of Hope will follow a structured approach to make sure that the car insurance card is updated and available and establish procedures to maintain compliance according to minimal standard


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

raw_content: Several of the employees' files and children files were missing current trainings and required documents.

Correction Narrative: True Home of Hope will implement steps to ensure that all employees and children files are up to date with the required training, documents, printed out certificates for all employees, helping to maintain compliance In accordance with minimal standard.


summary: 748.2461(b)(6) - Short Personal Restraint-Caregiver may not use restraint that twists or places the child's limb(s) behind the child's back

raw_content: A caregiver restrained a child in care by placing the child's hands behind their back.

Correction Narrative: Director conducted a staff meeting and reiterated the proper ways to perform a restraint per their most recent EBI training that occurred April 14th of 2024. Director also redirected staff to use other modes of de-escalation prior to utilizing EBI. Corrective plan emailed, reviewed, and uploaded.


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

raw_content: All foster children interviewed stated that staff yell at them.

Correction Narrative: Director held a staff meeting to reiterate the minimum standard to avoid future violations and citations. Corrective plan emailed, reviewed, and uploaded.


summary: 748.1111(a)(2) - Child Rights contact others-Not listen to or screen child's calls without permission from parents, service planning team, treatment director, or PLSP

raw_content: A foster child and their case worker stated that they were not allowed a private phone call.

Correction Narrative: Director stated that children were abusing phone privileges by being untruthful about who they were calling. To prevent contact with unauthorized children/people, she would step in momentarily to screen the call and leave immediately after. Picture of phone policy uploaded to document library. Corrective plan was emailed and uploaded.


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

raw_content: All but 1 child in care interviewed had a consistent account of staff swearing.

Correction Narrative: Director stated that the incident, if remembered correctly, involved a staff member that was reiterating to the children what she would not tolerate them listening to- Specified profane words. However, the staff was redirected to use more vague language when addressing the children about their inappropriate activities, to prevent children from being exposed to staff using said language.


summary: 748.2455(a)(1) - Emergency Behavior Intervention-Before using EBI, the caregiver must attempt less restrictive interventions that prove to be ineffective

raw_content: A caregiver did not attempt a less restrictive method prior to the use of restraint.


summary: 748.453(a)(3) - Unauthorized Absence  Annual summary log must include how long the child was gone or if the child did not return

raw_content: The annual summary log provided did not meet the criteria to be the unauthorized absence summary log as it did not contain any of the necessary information required by the minimum standards.

Correction Narrative: True Home of Hope caregivers must document unauthorized absences in an annual summary log, adhering to minimum standards. Details should include the duration of the absence or whether the child failed to return. In the event of three unauthorized absences within a 60-day period, a triggered review of the child's unauthorized absences is required, aligning with minimum standards. Furthermore, the organization must conduct an operational evaluation for unauthorized absences every six months as required. Annual summary logs must be readily available for review by Licensing upon request. The Director was able to present a revised copy of the unauthorized absence log including the necessary information.


summary: 748.303(c) - Serious Incident- Doc unauthorized absence that does not meet the reporting time reqs defined in subsection (a)(8)-(10) of this section in 24 hrs

raw_content: All unauthorized absences are not being documented as required.

Correction Narrative: True Home of Hope caregivers must document unauthorized absences in an annual summary log, adhering to minimum standards. Details should include the duration of the absence or whether the child failed to return. In the event of three unauthorized absences within a 60-day period, a triggered review of the child's unauthorized absences is required, aligning with minimum standards. Furthermore, the organization must conduct an operational evaluation for unauthorized absences every six months as required. Annual summary logs must be readily available for review by Licensing upon request. The Director confirmed that the log was created, the staff was made aware of the requirements to document unauthorized absences in a timely fashion.


summary: 748.2855(b) - EBI Documentation-Supervisors of caregivers involved in EBI must document review of the intervention within 72 hours of the incident

raw_content: The EBI documentation was only documented but not reviewed by anyone.

Correction Narrative: True Home of Hope Program Administrator is responsible for ensuring that all caregivers involved in EBI (Emergency Behavior Intervention) adhere to minimum standards. This includes promptly conducting a review of interventions within 72 hours of an incident and signing off on documents. Compliance with these standards is essential for maintaining the safety and well-being of the children under care. The Director confirmed that the administrator was made aware of the responsibility to review EBI documentation.


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

raw_content: During altercations multiple times bystanders unrelated to the operation had to help separate the children. In addition, staff present at the time did not intervene.


summary: 748.1351 - Initial Service Plan-Implement & follow plan as soon as all team members have reviewed/signed it, but no later than 15 days after date of meeting

raw_content: A child's initial service plan was not followed specifically the child's supervision needs. In addition, the service plan was not signed by all required parties.

Correction Narrative: True Home of Hope Treatment Director must ensure comprehensive assessments for child placement and ongoing evaluations. Responsibilities include organizing medical and psychological appointments, issuing monthly reports, and managing admission and discharge summaries. Additionally, develop service plans tailored to address the child's supervision and treatment needs. All team members are required to review and sign the Initial Service Plan within 15 days. The Program Administrator is responsible for enforcing all minimum standards consistently and ensuring the availability of all reports and records for Licensing staff review. The Director confirmed that her treatment team are aware of their responsibilities concerning service plans.


summary: 748.1331(b)(3) - Preliminary Service Plan-For child receiving treatment services, include description of how operation will meet child's needs

raw_content: The children's preliminary service plans does not address their supervision needs or plans on meeting the child's supervision needs.

Correction Narrative: True Home of Hope Treatment Director must ensure comprehensive assessments for child placement and ongoing evaluations. Responsibilities include organizing medical and psychological appointments, issuing monthly reports, and managing admission and discharge summaries. Additionally, develop service plans tailored to address the child's supervision and treatment needs. All team members are required to review and sign the Initial Service Plan within 15 days. The Program Administrator is responsible for enforcing all minimum standards consistently and ensuring the availability of all reports and records for Licensing staff review. The Director reported that the treatment director and administrator have been made aware of their responsibilities as it concerns service plans addressing supervision needs.


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

Deficiency Narrative: Staff used inappropriate language towards and in the presence of the residents.


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

raw_content: During the review of staff training records, there was no certificate or log to provide proof of suicide completion training/prevention.

Correction Narrative: Suicide training was completed in a timely manner. Supporting documents were submitted and uploaded.


summary: 748.753(a)(1) - Pre-Employment Screening-You must complete reference checks by obtaining the name and contact info of two individuals who can serve as references.

raw_content: During the review of staff records, reference checks have not been completed prior to staff being hired in 1 staff record.

Correction Narrative: Reference check form was completed with appropriate responses.


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

raw_content: Neither preliminary service plan was available for Childcare licensing to reveiw.

Category: Admission, Service Planning, Discharge

Correction Narrative: Ms. Rogers sent the preliminary service plans for both of the children's files we read. They will be uploaded to document library.


summary: 748.3273(8) - First Aid Kits-Each one must contain thermometer

raw_content: The first aid kit in the downstairs bathroom was missing a thermometer and cotton balls.

Correction Narrative: The administrator sent pictures of the cotton balls and thermometer that were added to their first aid kit.


summary: 748.3101(2) - Fire Inspection-Must have fire inspection at least once every 12 months from date of last fire inspection

raw_content: Upon follow-up inspection, it was gathered that the renewal of the fire permit for the facility has not been completed. It must be stressed that during the inspection of 11/14/2023, the facility was given Technical Assistance for the renewal of the fire permit. Thus, the facility's failure to timely renew the aforementioned fire permit merits a deficiency.

Correction Narrative: The facility sent a copy of the Fire Inspection Result dated 11/30/2023. Said Fire Inspection Result is uploaded in the document library.


summary: 748.3001(a)(2) - Sanitation Inspection-Sanitation official must conduct sanitation inspection at least once every 12 months from date of last inspection

raw_content: The health/sanitation inspection for the facility is long overdue, having been last renewed on 9/2/2022.

Correction Narrative: The operation provided a copy of a letter from Harris County Public Health (HCPH), stating that HCPH does not conduct environmental health inspections for foster or foster group homes. This letter is valid from January 1, 2024 to December 31, 2024.


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

raw_content: Upon inspection, installation of gas supply was not yet completed. And, while the facility owners contacted the service provider, it must be emphasized that the installation and provision of gas supply should immediately be done and prioritized.

Correction Narrative: Upon personal inspection, the stove was observed to be operational with gas supply. When turned on, the stove was lit with fire and there were no leaks or other concerns noted.


summary: 748.191(1) - Required Postings-Post the permit in a prominent and publicly accessible place where others may easily view it at all times

raw_content: During the walk-through of the home, it was observed to be missing the posted permit for the operation. This was corrected at inspection and the permit was posted.


summary: 748.831(a) - Orientation-Each caregiver or employee must have orientation prior to beginning job duties or having contact with children in care

raw_content: During inspection, two of two staff files reviewed were missing job descriptions.

Category: Training and Professional Development

Correction Narrative: The operation provided staff records that included employee's description.


summary: 748.105(4) - Personnel Policies - Develop written policies on the training requirements for employees

raw_content: Personnel policy does not include written training requirements for employees and caregivers.

Correction Narrative: The operation provided written training requirements for employees and caregivers.


summary: 748.111(16) - Child-care policy - Your plan for providing health-care services to a child with primary medical needs

raw_content: Child care policy does not include plan for providing health-care services to a child with primary medical needs

Correction Narrative: The operation provided a health care plan for children with primary medical needs.


summary: 748.105(3) - Personnel Policies - Develop written professional staffing plan

raw_content: During inspection, there  was no  written professional staffing plan.

Correction Narrative: The operation provided documentation of their written professional staffing plan.


summary: 748.107(2) - Conflict of interest policies-statement that majority of members of the governing body must consist of persons who do not have a conflict of interest

raw_content: no statement that the majority of the voting members of the governing body must consist of persons who do not have a conflict of interest

Correction Narrative: The operation provided documentation acknowledging that members of the governing body who do not have a conflict of interest.


summary: 748.109(2) - Admission Policies - include characteristics of the population the program serves

raw_content: App says age range is 7-17, admissions policy says 1 month-17, Op main page states they will not provide services for children with ED, admissions policies say they will

Correction Narrative: The operation sent a revised copy of their policy to reflect that they will receive children 7 years old to 17 years old.


summary: 748.111(12) - Child-care policy - Child grievance procedures

raw_content: Child care policy does not include child grievance procedures

Correction Narrative: The operation provided a revised policy for child grievance procedures.


summary: 748.4653(b) - Pre-Service Training-Document the completion of each pre-service training requirement in the appropriate personnel record

raw_content: During inspection, one of two staff files reviewed did not include training certificates for pre-service training for Normalacy, Transportation, Orientation, EBI, and Trauma.

Correction Narrative: The operation provided training certificates for pre-service training for Normalacy, Transportation, Orientation, EBI, and Trauma.


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

raw_content: During inspection, two of two child files reviewed did not include serious incident reporting form.

Correction Narrative: The operation provided documentation that included serious incident reports.


summary: 748.107(8) - Personnel Policies - Ensure that persons working with children or with access to child info are informed in writing of confidentiality requirements

raw_content: Personnel policy does not mention caregivers, volunteers, etc responsibility to maintain child confidentiality.

Correction Narrative: The operation sent a revised personnel policy to reflect mention caregivers, volunteers, etc responsibility to maintain child confidentiality.


summary: 748.1205(a)(13) - Include any risk factors/warning signs and safety plan staff/caregivers will implement related to the risk factors and warning signs

raw_content: During inspection, two of two child records did not include suicide risk assessment.

Correction Narrative: The operation provided records that included children's suicide risk assessment.


summary: 748.393(b)(2) - Active child record-Includes known allergies and chronic conditions or "no known allergies" on exterior of record or in a clearly visible location

raw_content: During the inspection, two mock child files were reviewed and it was noted that the files did not include documentation of known allergies and chronic health conditions on the exterior of the child s record or in another place where the information is clearly visible to persons with access to the record.

Correction Narrative: The operation provided documentation of known allergies and chronic health conditions.


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

raw_content: During inspection, two of two staff records reviewed were missing job descriptions.


summary: 748.109(1) - Admission Policies - Include program's goals and services provided, including whether emergency admissions accepted

raw_content: Admissions policy does not provide a description of the program s goals


facility_name: Aim to Achieve Ranch

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

raw_content: A caregiver pulled on a child's hair multiple times as a means to get the child under control.

Correction Narrative:
An corrective action was received via email on 03/06/2026 as it relates to this standard stated the following:
	The caregiver responsible has been discharged from her position. Aim to Achieve maintains a zero-tolerance policy for improper or inhumane discipline. To prevent recurrence, all staff will receive refresher training on proper redirections, de-escalation, safe positioning, and correct EBI techniques.
An inspection was conducted at the operation which included staff and child interviews to ensure compliance.
Staff termination was verified via administrator and inactivated on the people list.


summary: 748.2551(c)(1) - EBI Implementation-Caregiver must minimize risk of physical discomfort, harm, or pain to the child

raw_content: In a review of the investigation, it was found that a caregiver pushed down on a child's face.

Correction Narrative:
An corrective action was received via email on 03/06/2026 as it relates to this standard stated the following:
	The caregiver responsible has been discharged from her position. Aim to Achieve maintains a zero-tolerance policy for improper or inhumane discipline. To prevent recurrence, all staff will receive refresher training on proper redirections, de-escalation, safe positioning, and correct EBI techniques.
An inspection was conducted at the operation which included staff and child interviews to ensure compliance.
Staff termination was verified with the administrator and inactivated in the people list.


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: There were multiple children present during the inappropriate restraint. There were two staff members present during the altercation, and one staff member did not remove the other children present.

Correction Narrative:
A corrective action email was received on 03/06/2026 as it relates to this standard stating the following;

	All staff will be retrained in safety responses. This training focuses on removing other children from the area to protect the privacy and safety of any child experiencing a crisis or difficulty self-regulating.

An inspection was conducted at the operation which included staff and child interviews to ensure compliance.


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

raw_content: During an incident between a staff member and a resident, another staff member was present but did not intervene and assist the staff member.

Correction Narrative:
A corrective action was received via email on 03/06/2026 stating the following:

	All personnel will be retrained on intervention responsibilities, teamwork during crises, and the "tap-out" system. Furthermore, supervisors will conduct monthly check-ins to ensure team efforts remain consistent and appropriate.
An inspection was conducted at the operation which included staff and child interviews to ensure compliance.


summary: 748.4205 - Placement Extension-child receiving emergency care services may stay in care without a placement extension for a maximum of 15 days

raw_content: Five children receiving emergency care services have been in care longer than the maximum 15 days allowed. The operation has not submitted placement extensions.

Standard Risk Level: Low

Correction Narrative: The operation submitted variance requests for the placement extensions. Submission reviewed and approved in CLASS. Approval letters sent to the operation for placing in child records.


summary: 745.651(2)(A) - Background Check Validation  Every 3 months each operation, other than a licensed, registered, or listed home, must validate current list

raw_content: The requirement of validating the people list hasn't been met.


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: An employee no longer associated with the operation background check hasn't been inactivated after the seven day requirement.


summary: 748.3301(i) - Physical Site-Equipment and furniture must be safe for children and must be kept clean and in good repair

raw_content: During inspection of the children's bedrooms, the beds were observed to have splinters and exposed pieces of wood (newly built beds and ladders) that could cause injuries. Slats of some of the beds were found to not have been properly secured to the bed frame. One slat was observed on the floor under the bed.


summary: 748.3397(d)(2) - Bathing-Provide sufficient hot water to meet the demands of the children

raw_content: During the inspection of bathrooms and kitchen, it was observed that none of the hot water faucets produced sufficient hot water. After a further inspection of the hot water heater, it was determined that the pilot light was out and cannot be readily reset.


summary: 748.103(b)(10) - Policies and procedures to submit - Abuse and neglect

raw_content:
The operation's abuse and neglect policy reviewed is not consistent with 748.121. The policy does not address the following:
-Methods for increasing employee awareness of issues regarding child abuse and neglect
-Strategies for coordination between the operation and appropriate community organizations
-Methods for increasing employee awareness of prevention techniques for child abuse and neglect
-Actions that the parent of a child who is a victim of abuse or neglect should take to obtain assistance and intervention.


summary: 748.2003(a) - Administration of prescription medication-inform medical consenter of benefits/risks/side effects/treatment/consequences of refusing them

raw_content: The operation's medication administration policy does not fully address the requirements in informing the person legally authorized to give medical consent.

Correction Narrative: The operation submitted revised medication administration policy that meets compliance.


summary: 748.103(b)(6) - Policies and procedures to submit - Emergency behavior intervention

raw_content:
The operation's EBI policy contained on pages 85-92 were reviewed. The EBI policy:
-does not provide a complete description of the EBI caregivers may use, only names the curriculum.
-does not identify the specific techniques the caregivers can use, only names the two types of EBI allowed to use.
-does not include the determination of the basis for the EBI; does not address instructions for caregivers on attempting less restrictive behavior interventions that prove to be ineffective at defusing the situation; does not address requirements under 748.2551; does not address requirements under 748.2553(2), 748.2601, 748.2603, 748.2801(2), and 748.2805(2).
-does not address the caregiver's responsibility for documentation following use of EBI as required by 748.2853 and 748.2855(a).
-does not address notifications to the managing conservator when EBI is used with a child.
-does not address triggered review requirements of EBI for a specific child 748.2901 (Personal Restraints), 748.2903, 748.2905, 748.2907, and 748.2909.
-does not include the operation's requirement to conduct quarterly EBI data collection.
-does not include the operation's requirement to conduct an annual operation evaluation of EBI.


summary: 748.111(9) - Child-care policy - Plans for meeting educational needs of each child

raw_content: The operation's education policy does not address requirements in 748.1303.

Correction Narrative: An email was sent to rccr staff from the operation staff on 11/10/2022 with the updated education policies that reflected the required missing information.


summary: 748.103(b)(5) - Policies and procedures to submit - Child-care

raw_content:
The operation's child care policies do not address a childs right to correspond by phone and mail with family members and friends, how a child obtains clothing, does not address how teenagers are provided reasonable opportunities to select clothing, nor policies regarding mail restrictions and receipt of electronic messages and mail.

The operation's child care policies do not address care for pregnant teens that is consistent with 748.111(15). **The operation's admission policy does not indicate that this population of youth are accepted or excluded from admission.

The child care policies do not address nutrition and hydration for children in care that is consistent with 748.1691, 748.1693, 748.1697, 748.1699, 748.1701, and 748.1703.


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

raw_content: The medication administration and documentation policy does not provide clear instructions to staff regarding the required timeframe for recording medication administration.

Correction Narrative: The operation submitted revised medication administration and documentation policy. Policy reviewed meets compliance.


summary: 748.537(a) - On Call Staff-A person designated to handle emergencies must be on call and accessible to caregivers

raw_content:
The operation's professional staffing plan does address plans for handling emergencies.
The professional staffing does not address a designated person must be on call and accessible to caregivers and that all caregivers (and CCR) are informed of emergency system and how to contact the person on call.

Correction Narrative: The operation submitted an updated professional staffing and a disaster/emergency plan.


summary: 748.3709(1) - Higher Risk Activity-There must be a person that is responsible for and supervises a higher risk recreational activity

raw_content: The operation's recreation policy describes camping, hiking, fishing, and building construction as recreation activity opportunities offered and planned. However, the recreation policy does not address requirements for when children participate in higher risk recreational activity. The operation's recreation policy must meet or exceed 748.3709 thru 748.3713 and 748.3841 thru 748.3861, as applicable.

Category: Recreation Activities

Correction Narrative: The operation submitted revised recreation policy that removes recreation opportunities that are considered high risk activities. The operation does not intend to provide high risk recreation activities.


summary: 748.103(b)(1) - Policies and procedures to submit - Related to record keeping, including where records will be located.

raw_content:
The operation's policy on reporting serious incidents is missing significant policies and procedures for reporting serious incidents and other occurrences.

The policy is missing notification requirements as applicable in 748.317 and 748.319. The operation must use form 7266 "Notification of Abuse/Neglect/Exploitation Deficiency" to notify parents of the deficiency. These changes to the minimum standards were in effect April 2021.

The policies must be consistent with Subchapter D, Div 1- Reporting Serious Incidents and Other Occurrences. Serious incident reporting requirements were updated in minimum standards effective April 2022.


summary: 748.2855(a)(6) - EBI Documentation-Must include the length of time the child was restrained or secluded

raw_content:
The EBI incident form does not include requirement for staff to document the length of time a child was restrained.

The EBI incident form does not include requirement for staff to document a child's condition following the release from an EBI as required under 748.2855(a)(11).

Category: Emergency Behavior Intervention

Correction Narrative: An email was sent to rccr staff on 11/14/2022 from the operation staff of an EBI Incident form that reflected the required total time of the Emergency Behavior intervention.


summary: 748.3369(d) - Bedding-A bunk bed must be equipped with a securely attached ladder capable of supporting the child using the bed and an employee

raw_content: The bunk beds for children do not include securely attached ladders as required.


summary: 748.2103(b) - Medication Destruction-Discontinued or expired meds & meds left at facility destroyed by health-care professional/pharmacist or LCCA & adult witness

raw_content: The operation's medication policy does not address how discontinued or expired medications are to be destroyed.

Correction Narrative: Operation submitted correct medication policy that meets compliance.


summary: 748.3231(b)(2) - Evacuation-Plan requires person in charge during emergency to make an employee responsible for securing medical consents & medications

raw_content: The operation's disaster and emergency plan does not designate an employee responsible for securing childrens emergency numbers, emergency medical authorizations, and medications during the emergency.

Correction Narrative: The operation submitted an updated disaster and emergency plan that meets compliance.


summary: 748.105(2) - Personnel Policies - Develop written job descriptions including minimum qualifications and job responsibilities for each position

raw_content:
-Employee job descriptions are not consistent with 748.505 minimum qualification requirements and 748.507 general responsibilities requirements.
-There is not a job description for the required position of a Professional Level Service Provider.
-The administrator's job description is not consistent with 748.535-responsibilities of administrator. Chapter 748 SC E-Child Care Administrator responsibilities have been updated as of April 2022.

Correction Narrative: An email was sent to rccr staff from the operation staff on 11/10/2022 with the plsp job description. After reviewing the information, it was determined that the job description is missing information. An extension was granted in order to give the operation staff time to make provisions to the job description. An updated plsp job description was sent to rccr staff via email from the operation staff on 11/14/2022 with all of the requirements to meet the plsp job description.


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

raw_content: The serious incident form does not include requirements for documentation that is consistent with 748.313(3)(B thru E) and 748.313(4).

Correction Narrative: An email was sent to rccr staff on 11/10/2022 with the incident report template that reflected the required changes.


summary: 748.103(b)(7) - Policies and procedures to submit - discipline

raw_content:
The operation's discipline policy does not address:
-who may discipline a child
-explanation to staff what is considered "unproductive work"
-restriction of child's activities as a behavior management tool consistent with 748.2309


summary: 748.4009(a) - General requirements-Driver & caregivers must have clear instructions in handling transportation emergencies

raw_content: The operation's policy and procedures does not include plans for handling transportation emergencies that is consistent with 748.4009 (a) thru (c).

Correction Narrative: Operation's revised transportation policy was reviewed and meets compliance.


summary: 748.105(6) - Personnel Policies - Ensure that personnel policies comply with background check requirements

raw_content:
The operation's background check policy is not consistent with TAC Chapter 745, to include, but not limited to:
-requirements for when to submit for an initial background check that is consistent with 745.621
-determinations regarding background checks consistent with 745.641 and 745.651
-745.673 pertaining to subject of BGC at operation is under investigation for child abuse or neglect
-745.681 pertaining to risk evaluations

Correction Narrative: The operation submitted revised policy regarding background checks. Policy meets compliance.


summary: 748.105(4) - Personnel Policies - Develop written policies on the training requirements for employees

raw_content:
The operation's staff training policy was reviewed.
The policy does not include the following for general pre-service training:
-location and use of fire extinguishers and first aid equipment
-curriculum components for pre-service training in normalcy
-curriculum components for pre-service training in administering psychotropic medication
-requirement that training on administering psychotropic medication must be instructor led training and the instructor must be a health care professional or a pharmacist

The policy does not include the following for annual training:
-curriculum components for normalcy
-curriculum components for administering psychotropic medication
-psychotropic medication instructor led training requirement


summary: 748.3369(e) - Bedding-Bunk bed must have attached bedrails; bedrails & the mattress supports must not be an entrapment hazard

raw_content: Children's bunk beds are not equipped with required bedrails.


facility_name: Kismet Residential Treatment Center

summary: 748.3117(a) - Fire Extinguisher-Company licensed by State Fire Marshal must inspect each fire extinguisher at least annually & conduct any service or testing

raw_content: Three fire extinguishers observed at the operations were last serviced in May of 2024.

Correction Narrative: Operation advised that staff were spoken to regarding importance of having fire extinguishers serviced yearly and placed reminders on both their google and cell phone calendars to remind them 2 months prior to due date to schedule the service. Operation provided photo of recently serviced fire extinguisher.


summary: 748.363(8) - Personnel records - Include a Pre-Employment Affidavit for Applicants for Employment as specified in Texas Human Resources Code §42.0563

raw_content: During the monitoring inspection it was discovered that all personnel file reviewed were missing Form 2912, The pre-employment affidavit

Correction Narrative: The facility responded: During the Pre-Employment process, all future applicants will be required to complete the 2912 Form. This form has been attached to the Kismet RTC Employment Application. Also, the 2912 Form has been implemented in the pre-employment standardized checklist, for all required documents prior to hiring and onboarding. The Director of Human Resources will ensure that all pre-employment documents (including the 2912 Form) are collected and verified prior to hire.


summary: 748.455(a)(2) - Unauthorized Absence - Debrief include trauma informed strategies child can use to avoid future unauth absences & how op. can support strategies

raw_content: During the monitoring inspection it was discovered that 2 of the serious incidents reviewed were missing the informed care strategy to avoid future occurences.

Correction Narrative: The facility responded: The trauma informed care strategies designed to prevent future unauthorized absences, and the operational support for these strategies have been incorporated into the Unauthorized Absence Debriefing Form. Additionally, all staff members have been notified and oriented on the appropriate debriefing procedures to follow when a child returns from an unauthorized absence.


summary: 748.1209(b)(6) - Child Orientation-Include policies on emergency behavior intervention, including policies & practices on the use of personal restraint

raw_content: During the inspection reviewing child records 1 out of the 4 active records reviewed did not contain the child's preferred de-escalation techniques that caregivers can use to assist the child in the process.

Correction Narrative: The operation responded all admission documents (including the EBI Policies and procedures) will be reviewed prior to being scanned in shared drive. Also, the documents will be reviewed to ensure all signatures and information captured at the time of admission, is properly documented in each childs record.


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

raw_content: Two out of four active youth files reviewed contained inaccurate names and non-personalized information in the preliminary service plan.

Correction Narrative: Each childs service plan, preliminary service plan, etc. will be reviewed after completion by the Executive Director to ensure errorless documentation. Monthly audits will be conducted by the Executive Director to ensure all documentation (i.e. service plans, preliminary service plans, and all other reports) are accurately completed.


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: During the inspection while receiving child records 1 out of 4 active child records reviewed was not signed.

Category: Children's Rights

Correction Narrative: All admission documents (including the Childs Rights) will be reviewed prior to being scanned in shared drive. Also, the documents will be reviewed to ensure all signatures and information captured at the time of admission, is properly documented in each childs record.


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 residence were able to jump the gate and elope from the operation due to lack of proper supervision.

Correction Narrative: Interviews conducted with children in care confirmed that staff does not leave them unsupervised and uses verbally redirection as an effort to prevent unauthorized absences.


summary: 748.705(b)(9) - Reasonable & prudent parent standard-must consider the supervision instructions in the child's service plan

raw_content: The child's service plan advises that she would be monitored in close proximity due to her behaviors, however the child was allowed to be outside alone, while staff watched her from inside of the facility.


summary: 748.753(a)(2) - Pre-Employment Screening-You must contact each of the two references to verify that the applicant is suitable to work with or around children.

raw_content: Three staff did not have any unrelated reference checks in their file.

Correction Narrative:
The operation stated:
Prior to the initiation of hire, the Director of Human Resources will complete the pre-employment process. This process will include at least 2-3 unrelated reference checks to determine if the applicant is suitable to work around children. The current reference check form has been revised to reflect the required information. Also, the current employment application has been revised to include unrelated references for each applicant to complete.


summary: 748.751(a)(2) - Pre-Employment Screening-You must contact the employer to verify if the applicant was employed as described in the applicant's employment history.

raw_content: It was found that only one previous employer was contacted for three current staff.

Correction Narrative:
The operation stated:
Prior to the initiation of hire, the Director of Human Resources will complete the pre-employment process. This process will include the verification of at least (3) employer reference checks. The employer reference checks will be documented and filed in each employee's file once hired. The current reference check form and employment application has been updated to include this information.


summary: 748.535(3)(C) - Child-care administrator responsibilities-Having system in place to ensure an employee is available for emergencies

raw_content: The facility was contacted & unresponsive for over an hour during an emergent situation involving a child in care.

Correction Narrative:
The operation stated:
Kismet Residential Treatment Center has re-developed and implemented a well-organized, and comprehensive plan for the availability of emergency contacts. (1.) A list of primary emergency contacts has been developed, as it pertains to each child in the care of Kismet Residential Treatment Center. This list has been provided to each child's legal team (i.e., caseworker, CASA, AAL, etc.) and uploaded to each child's Tomball ISD School Portal. (2.) The list has been established based on a hierarchy of contacts that are prioritized according to the emergency contact's availability, and proximity to the facility. This is to assist in determining the order in which each individual listed should be contacted, during different emergent situations. Also, to ensure that any/all emergent situations are addressed in a timely manner.
(3.) Secondary Contacts have been identified and listed if a primary contact is unavailable. (4.) All staff members have been informed of the communication protocol, as it applies to contacting individuals in emergent situations. All KRTC staff members have been made aware that all phone calls made to the facility, must be answered and/or routed to the appropriate individuals or departments. Any missed calls must be returned as soon as possible. (5.) KRTC will regularly review and update any emergency contacts to reflect changes in contact information. The child's school and legal team will be notified of any changes in writing.


summary: 748.1217(c)(12) - Admission Assessment-Prior to initial service plan, add recommendations for further assessments or testing

raw_content: 4 of 4 admissions assessments did not include any recommendations for further testing or assessments.

Correction Narrative:
Kismet stated:
All completed Admission Assessments will include any identified further testing or assessments. If there are no recommendations for further testing or assessments, this information will be documented in the Admission Assessment to ensure that this information is captured and documented appropriately.


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

raw_content: Records were not in the files after 30 days of occurrence. The Inspector arrived at the facility at 1030am, completed file records were not provided to the Inspector until 3pm.

Correction Narrative:
Kismet stated:
748.399(a) Records Available for Licensing-all active records immediately available for review and reproduction. (Weight: Medium)

	Records were not in the files after 30 days of occurrence. The inspector arrived at the facility at 1030am, completed file records were not provided to the inspector until 3pm. 	10/9/2023	All records will be made available for licensing immediately upon request. Also, Kismet will ensure that all records are electronically available for immediate production. This is to streamline the approach to document management and efficiency. This will allow access to the information needed quickly and reliably, improving overall productivity that ensures documentation is available in each child's eRecord prior to the 30-day occurrence. All access to eFiles and eRecords will be made available to licensing upon request. Kimset Residential will adopt best practices to also ensure that all records are assembled prior to the child's 30 days of placement at the operation. Also, all documents will be filed within 14 days of occurrence in each child manual file.


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: One out of five child files are missing signed child's rights.

Correction Narrative: Kismet stated: The child's rights form was unavailable because the file was locked in the office. Moving forward, Permit Holder Angie Bacon now has "a copy of her office key now just in case she forget to put the files in the file room.  All documents are also scanned and saved in our Google drive for immediate access."


raw_content: Three out of five children's files were unavailable at the time of inspection. They were on site, but in a locked room in which present staff did not have a key.

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

Correction Narrative: Kismet stated: Permit Holder Angie Bacon now has "a copy of her office key now just in case she forget to put the files in the file room.  All documents are also scanned and saved in our Google drive for immediate access."


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: Medications are located in a locked closet. However, the black file cabinet containing Schedule II medications was unlocked with the key inside the lock.


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

raw_content: A walk through of the facility revealed that there is an unpleasant odor emanating from the toilet and bathrooms in the girl's quarters. There is a need to regularly the grass in the backyard. A leaning pole at the backyard, behind the admin building, needs to be fixed.

Correction Narrative: Work orders were sent to address the issues pertaining to physical site.


summary: 748.3115(2) - Fire Extinguisher-Must ensure fire extinguishers are accessible for immediate use by employees, caregivers, & volunteers

raw_content: No fire extinguisher was placed in the hallway area where a fire extinguisher should have been placed. The fire extinguisher was eventually placed in the designated area and was inspected to be in good working condition.


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

raw_content: A medication error that occurred on 4/6/23 was not documented until 4/13/23.

Correction Narrative:
A medication error form was placed in the file at the time of inspection visit.  All medication passers will receive an in depth 2-hour medication refresher training on Thursday, April 20th.  The 2-hour training will be instructor led by Nidhin Joseph, Pharmacist and Larrina Rogers, ED.
The Administrator will file all certificates in the staff records and provide copies to CCR staff Ms. Barriere.

As part of the CAP starting 4/20/23; the ED or designee will review the medications and logs daily for accuracy.


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

raw_content: 1 of 1 medication logs had two medications, Aripiprazole and Hydroxyzine, with medication log counts and actual pill counts that didnt match.

Correction Narrative:
The Administrator will ensure that all medication passers will receive an in depth 2-hour medication refresher training on Thursday, April 20th.  The 2-hour training will be instructor led by Nidhin Joseph, Pharmacist and Larrina Rogers, ED.  The Administrator will file all certificates in the staff records and provide copies to CCR staff Ms. Barriere.
As part of the CAP starting 4/20/23; the ED or designee will review the medications and logs daily for accuracy.


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: The incident that warranted medical treatment for the children on 3/31/23 was not reported to licensing until 4/2/23

Correction Narrative:
Kismet stated:
Residential and Administrative staff have been made aware of that the EMS is considered a Medical Professional and if treatment is provided by this entity, it must be reported within 24hrs.  This will also be reiterated in our all staff meeting on Wednesday June 28th.


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

raw_content: The current Administrator was employed at another-non-contiguous operation.

Correction Narrative:
Administrative Review is being requested for this citation.

Administrator is not employed as an Administrator at any other residential childcare operation. Administrator will only be the LCAA for the current operation unless another Administrator assumes that role in the further. If this does occur the Inspector will be notified within the appropriate timeframe according to the Minimum Standards.


summary: 748.455(a) - Unauthorized Absence-After a child returns from unauthorized absence, foster parent must conduct debriefing w/child no later than 24 hrs after return

raw_content: Debriefing form not available for review.

Correction Narrative:
Kismet stated:
The debriefing form has been placed in the unauthorized absences binder and the mock child file. Please see attached form.


summary: 748.3351(5) - Interior Space-provide bedroom windows with curtains, blinds, shades, or other provisions for rest and privacy

raw_content: Bedroom windows did not have a covering for privacy.

Correction Narrative:
On 10/27/2022 a physical follow-up was conducted and compliance is met.

The Administrator met with the Contractor who stated he will have all the coverings on the windows by 10/15/22 for the children's privacy. A in person follow will be conducted to ensure compliance has been met.


facility_name: TLW Transformation Center

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: Based on interviews conducted, the operation is confirmed to bring out a cleaning cart with cleaning supplies daily into areas accessible to children in care who cannot use chemicals responsibly.

Correction Narrative:
TLW Transformation Center provided the following corrective action plan pertaining to INV #3194802: All chemicals will solely be kept in the janitor closet. During chore time, a staff will gather all cleaning supplies, spray the chemicals in the appropriate areas and lock them back in the janitor closet, then continue supervision of chores in the designated areas. Only gloves, towels and non-chemical related products will be accessible on the chore cart in proximity to clients.

Staff and child interviews were conducted to confirm that chemicals are no longer accessible to children in care. Interviews conducted did not indicate any violations of Minimum Standards.

An unannounced inspection was conducted on 03/26/2026. The inspector arrived in the middle of scheduled chore time. The inspector observed no chore cart or cleaning supplies out or accessible to children in care.


summary: 748.1101(b)(6)(C) - Children's rights-to confidential care/treatment, include keep medical & operation records private. Discussing them only when it's about child's care

raw_content: A child's personal information was not properly secured, resulting in another child being able to read sensitive information.

Correction Narrative:
The following corrective action was sent via email:
1) An immediate staffing was had with the staff to clarify the importance of covering any document in hand when a kid enters any executive offices.
2) A folder has been provided to be placed on each desk for immediate insertion if a kid enters an office.
3) Staff have been advised that if a kid walks into their office and they are working on a task pertaining to another kid, they can kindly ask the child to exit the office space until all confidential information has been secured.


summary: 748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean

raw_content: Restrooms were observed with dirty sinks and bathtubs had a black residue in the tile grout. Trash and dirty towels were present in tub.

Correction Narrative: The operation provided photos of regrouted tubs, and freshly painted doors and walls. The operation will continue to address work orders in a timely fashion.


raw_content: Two bathrooms were observed, and one had a clogged sink and the other a broken toilet handle.

Standard Number / Description: 748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean

Correction Narrative: Corrected


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

raw_content: During the inspection, multiple gnats were observed around the facility.


summary: 748.1101(b)(2) - Children's rights-Family contacts: maintaining regular contact with parents and siblings, unless restrictions needed because of child's best interest

raw_content: Multiple children in care and staff stated that personal phone calls are taken as a consequence.

Correction Narrative:
An email was received from the Administrator on 3/11/25 stated that when the clients' behaviors escalate due to the phone calls, and it is in the best interest of the client to have them not make a call to give them time to stabilize and have additional therapy before the next call.

When a consequence is given to any kid we meet with them, discuss the behavior that led to the consequence, and they sign acknowledging the information is accurate.

The children have 3 days a week for personal calls (Sunday, Tuesday and Thursday) and even if/when personal call restriction is used as a consequence it is noted for 1 day unless a different agreement is made with the caseworker's approval. So, they still have a minimum of 2 additional times each week to contact their approved family and friends as we support and promote positive communication for them as well.

The administrator attached a blank document that is used to make the child aware of their consequences and the circumstances surrounding the consequences.


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: Four out of four employee files reviewed did not contain documentation of reference checks and employment history checks completed.

Correction Narrative: An email was received from the operation's administrator which included the missing employee reference checks for verification.


summary: 748.505(b)(4) - Minimum qualifications for employees-Complete notarized Licensing Affidavit for Applicants for Employment form

raw_content: Four out of four employee files reviewed had Affidavit for Employment forms that were not notarized.

Correction Narrative: An email was received from the operation's administrator which included the originally incomplete affidavits completed and notarized.


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

raw_content: During the inspection, one out of 4 children's service plans reviewed was completed past the 45-day requirement.

Correction Narrative: During the inspection at the operation, the administrator stated she will be responsible for double checking with her case manager regarding required document timeframes moving forward to ensure they are being completed timely.


summary: 748.395(1) - Active child record - All documentation in the record no later than 30 days after occurrence or event

raw_content: Three out of four child files reviewed did not contain required documentation is the files within 30 days.

Correction Narrative: An email was received from the operation's administrator that included the missing documents from the children files.


summary: 748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication

raw_content: The name and signature of the person who administered the medication were missing. Photos of the missing staff signature were taken. The staff names and signatures of those who administered the medication log were updated to correct the deficiency.


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

raw_content: The unauthorized absence log report did not have the age of the child, date of admission, gender of child, and the staff that was present during the unauthorized absence.

Correction Narrative: An email was received from the operation's administrator that included a copy of the updated unauthorized absence log to include the missing details as added columns on the form.


summary: 748.2463(3) - Emergency Behavior Intervention-Never used as a means to get a child to comply

raw_content: Based on two incident reports, it was determined that staff used EBI to get the child to comply with getting back downstairs and to get back on task at school.

Correction Narrative: The operation conducted a training on February 21, 2024, regarding proper documentation and appropriate times to administer an EBI.


summary: 748.2855(a)(6) - EBI Documentation-Must include the length of time the child was restrained or secluded

raw_content: Two incident reports indicate a restraint occurred but does not have the length of time.  Two incident reports did not include the de-escalation attempts before or during the restraint. Two incident reports do not indicate that staff attempted to explain to the child what was required to be released from the hold.


summary: 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation

raw_content: This standard was found deficient as part of a DFPS investigation.

Correction Narrative: Corrected.


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: A youth in care obtained bruising by being pushed to the ground by a caregiver.


raw_content: One of three child files reviewed did not have a completed initial service plan.

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

Correction Narrative: An email was sent from the operation's owner, Synithia Harvey, that included a copy of the missing initial service plan.


summary: 748.2205(1) - Medication label error-Report medication label errors to the pharmacist

raw_content: It's suggested a designee is assigned to audit all medication immediately upon receiving from the pharmacy to ensure all medication labels are correct before administering. If a medication label has an error, the pharmacy should be notified immediately to have it corrected. This will ensure the youth in care is being administered medication per a health professional's orders.

Correction Narrative: An email was received from the operation's owner that included a copy of the email correspondence between operational staff and their pharmacy in regards to issues with receiving packaged medications that are incorrect count or not completely sealed upon receiving.


raw_content: Two out of three employees did not have an affidavit for employment completed in their files reviewed.

Standard Number / Description: 748.505(b)(4) - Minimum qualifications for employees-Complete notarized Licensing Affidavit for Applicants for Employment form

Correction Narrative: An email was received from the operation's owner that included a copy of the missing affidavits signed and notarized.


summary: 748.363(4) - Personnel records-Personnel records-Include current job description.

raw_content: Three out of three employee files reviewed did not contain a job description.

Correction Narrative: An email was received from the operation's owner that included a copy of the missing job descriptions signed.


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

raw_content: Based on the preponderance of evidence in this investigation, staff used inappropriate discipline towards a child in care which results in a deficiency of 748.2307(1)

Correction Narrative: Operation submitted re-training records and suspended the staff one week as a result of this investigation.


summary: 748.1101(b)(4)(A)(vii) - Children's rights- Free from demeaning behavior to embarrass/control/harm/intimidate/isolate the child

raw_content: Staff intimidated children in care using profane language in order to increase personal space.  Staff baited a child to strike them so law enforcement could be called.

Correction Narrative:
The operation reported conducting a recent training to address that addressed the minimum standard violation identified in this case.
On 12/13/2023 from 6PM to 745PM Trauma Informed Discipline training was conducted. The trainer discussed subchapter M Discipline and Punishment. Specifically, the training addressed prohibited punishment. A sign in sheet was provided to RCC identifying 18 unique signatures. Two of the signatures belong to the two staff identified in this investigation.


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: During the walkthrough of the medication room the medication cabinet was observed to be unlocked. Two children's medication boxes were observed to have Scheduled II substances in them.


summary: 748.1333 - Preliminary Service Plan-Treatment director or PLSP must develop, sign, and date the plan for children receiving treatment services

raw_content: Two out of three child files reviewed included a service plan that was signed by someone other than the Treatment Director or PLSP.

Correction Narrative: An email was received from the operation's owner that included a CAP detailing how the operation is changing their organization of active binders and who's responsible for ensuring their accuracy. It also indicated a routine audit will be implemented to ensure this is being completed correctly.


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

raw_content: Several documents reviewed were not completely filled in with dates and signatures missing.