summary: 748.685(c)(1) - Caregiver responsibility - be aware of children's habits, interests, and any special needs including supervision

raw_content: A child in care was left unsupervised in the bathroom for several minutes with the door closed. This was not consistent with the childs precaution plan, which requires staff to maintain line of sight supervision and keep the bathroom door open for safety.

Correction Narrative: An email was received by the operation on 11.19.25. A meeting was held with upper management to discuss the citation. A training was held with management regarding precautions and supervision levels. Unit Managers reviwed procedures with their units to ensure supervision is being attained.


state: TX

facility_name: Meridell Achievement Center

summary: 745.635(2) - AP Background check determination - If ineligible then you must immediately remove subject from operation and confirm to CBCU receipt of notice letter

raw_content: An administrative penalty will be recommended as a result of this citation, per HRC §42.078

Category: Individual Standards Evaluated

Standard Risk Level: High

Corrected at Inspection: No

Correction Narrative:
RCCR received an email from Mr. Scruggs for compliance on 7/18/25.
Standard 745.635 (2) AP Background check determination  if ineligible then you must immediately remove subject from the operation and confirm to CBCU receipt of notice letter.

The standard was reviewed with Human Resources department staff members and coaching/clarification was provided by Glenn Scruggs  the Licensed Child Care Administrator on 7/17/25 that when a staff member is deemed ineligible that they must be removed from the schedule that day, notify the CBCU that the employee has been removed from the schedule, and ensure that the staff member has been timely deactivated with the CBCU and is no longer associated with Meridell Achievement Center within the specified timeline per minimum standards.  I have advised that the HR department review the background checks and if there are any questions related to a background check that they consult with me as the Campus Administrator for guidance and clarification.  The HR department will review the provider login page at least twice a week to ensure that they are monitoring the background checks and other items that need to be addressed on the site.


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: Through interviews staff as well as documentation provided, it is determined one of the units on campus was out of ratio during the time of the altercation on 03/30/2025.

Standard Risk Level: Medium High

Correction Narrative: On 5/5/25 the operation indicated that they are having administrative staff review staffing schedules, continue to hire MHT's and nursing staff to ensure ratio. On 5/19/25 an inspection was conducted, and children were interviewed regarding ratio and language. No concerns noted.


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

raw_content: Residents interviewed consistently mentioned a staff member used profane language. One staff member was told by several residents that a staff member has use profane language.  Another staff member stated he had heard a staff member used profane language.

Correction Narrative: Residents were interviewed regarding cursing. Administrator also provided training to the staff involved.


summary: 748.2551(b)(2) - EBI Implementation-The caregiver must consider the permitted types of emergency behavior intervention

raw_content: An inappropriate restraint was completed by a staff on a child. Staff lunged at the child tackling the child to the ground. A proper hold could not be completed, but staff continued to wrestle with the child for 30-45 seconds until another staff responded.

Correction Narrative:
Although this is not pulling over into the INV follow-up, the inspection for this follow-up was completed on INSP# 4047160. CCR received an email on 3.10.25 explaining the staff that was involved in the investigation had been terminated.

RCCR VLopez conducted a follow up at Meridell on 3/14/25. Interviews with children and staff regarding Emergency behavior interventions, de-escalation, training, and caregiver responsibility.  No concerns were noted during these interviews.


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

raw_content: During the course of the investigation, a staff member admitted they did not intervene when an altercation took place between two children in care.


raw_content: Two children were observed arguing and then one of the children ran over to the other child's table to try and hit the second child. One of the staff placed themselves in between the two children and the other staff grabbed  the child by the arms and jerked them back away. Staff admitted the restraint was inappropriate.

Standard Number / Description: 748.2551(b)(2) - EBI Implementation-The caregiver must consider the permitted types of emergency behavior intervention

Correction Narrative:
Staff undergo verbal de-escalation and HWC training twice a year and are offered refresher courses as needed to ensure that they are properly administering holds when they are necessary.  Program Manager addressed the concern on the spot (1/11/25) while inspector was present, and staff member accepted the feedback.
On 2/20/25 RCCR conducted interviews with children and staff, they indicated that only permitted types of EBI are being used. The operation will continue to use refresher EBI training to ensure compliance. Inspection #4042200


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

raw_content: Grates in 4 of the doors at the gym were found to be bent. The pool was found to be dirty and the bottom could not be seen. Trash was foun through out all of the buildings.

Category: Physical Site

Standard Risk Level: Medium

Correction Narrative: The grates in the gym were inspected by Director of Plant Ops and replacement metal grates have been ordered (1/14/25) and will be replaced when they arrive at the facility.  The pool was shocked with chemicals (1/14/25) and the pool water is now blue and clear in color.  Staff were reminded (1/15/25) to pick up empty water bottles and as we discussed, the patients were involved in indoor arts and crafts activities which is why there was paper and art supplies on the floor int the dayroom areas.  Staff were instructed to be more proactive and to pick up things as they go through the activities to ensure there is not clutter present.


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

raw_content: Children interviewed stated a particular staff member yelled/raised her voice at them triggering a conflict.

Correction Narrative: On 2/10/25 RCCR interview children and staff and did not find concerns related to other prohibited punishment such as yelling or cursing.


raw_content: Children interviewed consistently mentioned a staff member mumbling profane language and derogatory words under his breathing about the children in care.

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: Interviews with children and staff indicate that employees are using prudent judgement while working with children.


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

raw_content: The staff in question stated they did an escort when the victim refused to leave the Dayroom. 3 Collateral Staff stated an escort was done because the victim refused to leave the Dayroom.

Correction Narrative:
The operation provided documentation of 1 week of suspension without pay for Marian Fields dated 12/3/24 for violating Policy HR 403  Aggressive behavior including but not limited to verbal or physical abuse/threats, swearing, or intimidating behavior directed towards a patient, visitor, or facility employee.
Training record for Mareion Fields dated 12/13/24. 4 hours of verbal de-escalation. Signed by trainer Jim Pennymore. Review of Key points in a crisis, working styles in crisis and stages, preventing power struggles, active listening, and tagging in or out.

On 2/10/25 RCCR held interviews with children and staff indicating that EBI is being used according to standards and not for compliance. The operation will continue to use refresher EBI training to ensure compliance. Inspection #4037759


raw_content: It was determined staff were unable to restrain the child using techniques that were approved by the facility. The staff and 3 collateral witnesses verified this information.

Correction Narrative:
The operation provided documentation of 1 week of suspension without pay for Marian Fields dated 12/3/24 for violating Policy HR 403  Aggressive behavior including but not limited to verbal or physical abuse/threats, swearing, or intimidating behavior directed towards a patient, visitor, or facility employee.
Training record for Mareion Fields dated 12/13/24. 4 hours of verbal de-escalation. Signed by trainer Jim Pennymore. Review of Key points in a crisis, working styles in crisis and stages, preventing power struggles, active listening, and tagging in or out.

On 2/10/25 RCCCR held interviews with children and staff indicating that only permitted types of EBI are being used. The operation will continue to use refresher EBI training to ensure compliance. Inspection #4037759


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

raw_content: During the investigation, it was discovered that a child's records was not documented accurately.

Correction Narrative: The operation has discussed the importance of true and accurate documentation and records with staff in staff meetings and training.


summary: 748.1553 - Child must be immediately treated by health prof, contact emergency svs or take child to ER for injury/illness requiring treatment by a health prof.

raw_content: Documentation reviewed determined a child was assessed and concerns of a  serious injury were suspected on 7/29/30 but the child was not given treatement until 7/30/24.  Upon Follow up it has been determined the facility will continue with their current protocols.

Correction Narrative: New protocol is that the nurse will assess a child's injury. During business hours Mobile X-Ray will be notified to come on the same day. During Holidays or after hours, nurse will assess. If X-Ray is need the Mobile X-Ray will be notified as STAT. If they do not arrive by the end of the shift the child will automatically be sent to the hospital. X-Ray mobile is contracted for 24/7 Service.


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: A caregiver failed to adhere to the child's rights to be free of abuse, neglect, and exploitation as defined in Texas Family Code 261.401.

Correction Narrative: Resignation Letter dated for 12/13/24 and review of the background checks validated the staff is no longer employed.


raw_content: Through the course of the investigation it was determined a child was called a brat in front of other staff and children.

Standard Number / Description: 748.2307(8) - Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child


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

raw_content: Review of the backgrounds found an employee had their background inactivated on 7-9-24 and is still having access to children in care.

Corrected at Inspection: Yes


summary: 748.1349(a)(3) - Initial Service Plan-Give copy or summary of plan to child's caregivers

raw_content: It was determined that staff caring for children do are not easily able to access the Service Plans for the children they are caring for.

Category: Admission, Service Planning, Discharge

Standard Risk Level: Medium Low


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

raw_content: In conducting a walk through of the facility a clogged toilet with feces, mildew in the bathroom, and toilet paper covered in bodily fluids.

Correction Narrative: Restrooms were found to be clean and all repairs made.


raw_content: Three of Seven Units were found to have repairs needed, peeling paint, broken furniture, broken or missing air vents, and trash in several rooms and on the grounds around the homes.

Standard Number / Description: 748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.

Correction Narrative: Operation must immediately remove the person from the operation until eligibility has been determined.


summary: 748.1005 - Child/caregiver ratio-Each group must have enough caregivers for that group who are not caring for other children or doing administrative work

raw_content: Three out of five collateral interviews stated the facility has been out of ratio. Another collateral made the statement "when the facility is in ratio" indicating there are times the facility is out of ratio.

Correction Narrative: Walk through of the dorms was completed. The facilities were in ratio and extra staff was observed going from unit to unit.


summary: 748.1009 - Child/caregiver ratio-Must employ an adequate number of caregivers to meet the needs of children

raw_content: Through interviews of children and staff as well as documentation provided, it is determined one of the units on campus was out of ratio on 9/13 and 9/14.

Correction Narrative: Walk through of the facility found staff were in ratio with the children.


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

raw_content: Multiple walls in units had derogatory writing on them. There were several bathrooms that had trash items in the sinks. One ceiling vent had what appeared to be mold or heavy dust on it. A bulletin board was observed to be broken in one of the rooms. Multiple units had large areas of peeled paint on the doors and walls.

Correction Narrative:
Walk through was done of the dorms. All repairs had been made.
The facility also hired a person to do nothing but paint.


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

raw_content: Treatment Plans, Interviews, and video were reviewed during the investigation and determined children were to be checked on every 15 minutes and two of those checks were missed.

Correction Narrative: Received notice from the Administrator that one of the staff involved resigned and the other was given counseling.


summary: 748.363(7) - Personnel records-Include notarized Licensing Affidavit for Applicants for Employment form as specified in Human Resources Code, 42.059

raw_content: 3 Staff Charts were reviewed did not have Licensing Affidavits.

Category: Reports and Record Keeping

Correction Narrative: Reviewed charts from inspection and a new hire charts and all had Notarized Licensing Affidavits.


raw_content: During the walkthrough of the operation childrens bathrooms were observed with mildew in the shower and bathroom sinks have excessive gunk.

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

Correction Narrative: Walk through was conducted of the units with no issues or concerns.


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 the interview, both the Administrator and the therapist stated the resident was left unsupervised.

Correction Narrative: All staff have been retrained on Supervision. Verified by signature sheets.


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

raw_content: A child in care sustained a fracture to their hand as confirmed by X Rays results that were provided to the operation on 5/11/24. The operation did not report this to Licensing until 5/14/24.

Correction Narrative: Staff was retrained on timeframes and what to report as a Serious Incident.


summary: 748.681(1)(B) - Caregiver qualifications-Must be at least 21 yrs old if all children in group are 13 yrs old or older

raw_content: In reviewing the investigation it was found a  person that was not a qualified caregiver was interacting with children and was left to supervise the children.

Correction Narrative: The staff was counseled on job description. The employee that asked the staff to watch the children is no longer employed. The facility has put into place you must be 21 years old to be employed.


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

raw_content: Three out of five children interviewed stated a staff member will cuss at them.

Correction Narrative: Staff was retrained and placed on Performance Improvement Plan


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

raw_content: Documenation and interviews verified the child was recommended for a follow-up on 1/23/24 and did not receive it.

Correction Narrative: Nurse Manager stated they now have hired more Milieu workers to help transport. When a follow-up is given it is entered into the system and put on the calendar to ensure there is a transporter that day.


summary: 748.1337(b) - Initial Service Plan-Document in child's record and include preliminary service plan requirements

raw_content: In reviewing the Admission Assessment, Preliminary Service Plans, and  Initial Service Plans, several items that are required were found not to be included.

Correction Narrative: Corrections for this have been added to the POA. Also the facility has begun to transform their forms.


raw_content: In reviewing background checks if was found two employees did not have active backgrounds checks.

Standard Number / Description: 745.641 - AP Background check results - Must receive notification prior to allowing subject to be present at your operation

Correction Narrative: People List reviewed and backgrounds had been completed.


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

raw_content: During the walk through a staff was observed in the Nurse's Station on their personal phone while 4 chidlren were out in the Day Room alone.

Correction Narrative: Walk through was conducted. Staff interviewed. Ratio was found in compliance. Staff were retrained in April signed attendance forms.


summary: 748.303(a)(4)(A) - Serious Incident-Report to Licensing as soon as aware of an incident of physical abuse of a child against another child

raw_content: In reviewing Serious Incidents it was found a fght occurred in which a child was iinjured and taken to the doctor, but never reported.

Correction Narrative: All staff retrained. Training Logs acquired


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

raw_content: Interviews from 6 persons validated that staff yelled at children when behaviors started to escalate.

Correction Narrative: All staff were retraiined on Trauma infromed care.


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

raw_content: Interviews validated there was no documentation written for the restraint.

Correction Narrative: A new EBI form was created and staff were retrained on Serious Incident Reporting.


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

raw_content: 3 staff and 3 children noted staff are passive aggressive and/or rude towards the children.

Correction Narrative:
An email was received on 5.2.24 from the Administrator. Pt. Advocate will respond to all patient complaint forms and address written complaints with patients on a weekly basis.  Documentation of the patient complaint forms with the outcome/resolution are available for review with the patient advocate.  Any employees who are confirmed to have violated patient rights will be referred to their immediate supervisor for coaching, retraining, and possible disciplinary actions, as necessary.
Administrator has been working to hire new employees, retrain the current employees, and release staff that are not following the Minimum Standards.


raw_content: 3 staff and 1 child stated staff use profane language around and/or towards the children in care.

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

Correction Narrative:
An email was received on 5.2.24 from the Administrator. Pt. Advocate will respond to all patient complaint forms and address written complaints with patients on a weekly basis.  Documentation of the patient complaint forms with the outcome/resolution are available for review with the patient advocate.  Any employees who are confirmed to have violated patient rights will be referred to their immediate supervisor for coaching, retraining, and possible disciplinary actions, as necessary.
Staff have been retrained on caring for children.


raw_content: 5 staff and 2 children stated staff yell at children in care.


summary: 748.1007(b)(1) - Child/caregiver ratio-Awake caregiver may care for 15 children if any child in group requires treatment services

raw_content: The operation was out of ratio overnight on at least 3 occurrences in 1-2 units.

Correction Narrative:
An email was received on 5.2.24 from the Administrator. Campus Administrator is working alongside the Program and Nursing Departments to ensure that ratios and staffing patterns are in compliance with standards. The schedule tool Shift Hound, which Meridell utilizes is being reviewed and updated daily to reflect current, true, accurate, and complete records of staffing on the units.
Schedules were reviewed and found there were not staff scheduled for the amount of children in placement.


raw_content:
A physical altercation occurred on 3.28.24 in a unit that was out of ratio. Due to this, a child had to call the code to get additional staff to respond.
Not having enough staff to respond to codes was brought up numerous times during interviews with children and staff.
Additionally, an incident occurred where a child was left in a unit for approximately 15 minutes without a staff. The nurse was double covering that day and staff believed the nurse was inside, however, she had left to check on the other unit.

Standard Number / Description: 748.1009 - Child/caregiver ratio-Must employ an adequate number of caregivers to meet the needs of children


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: The operation was out of ratio during the day on at least 3 occurrences in 1-2 units.


raw_content: Four of the Seven Units were observed out of ratio and a group was observed out of ratio while walking to dinner.

Standard Number / Description: 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

Correction Narrative: Conducted unannounced inspections of the 4 units and they were found to be in compliance of ratio.


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: It was determined children were exposed to explicit content when a staff member screened their phone to the television.

Correction Narrative: An Inspection on 6/20/24 it was determined the staff was terminated and was no longer associated with the facility.


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

raw_content: Documentation determined the victim was walking away from the situation when the staff  chose to restrain the child.

Correction Narrative: All staff were retrained on EBI.


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

raw_content: It was found the staff involved in this case had EBI training 7/27/23 which expired in January and did not have current training at the time of the incident.

Correction Narrative: An Excel Spreadsheet has been created with all personnel and the due date for their next EBI training.


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

raw_content: It was noted during a walkthrough that multiple bathrooms had feces on the walls.  One room had a rotten food product in the sink.  Food smears were noted in multiple rooms.

Correction Narrative: Walk through was conducted of 4 of the Units and found to be in compliance.


summary: 748.685(c)(2) - Caregiver responsibility - provide a safe environment

raw_content: Staff were iinterviewed and were unaware and unable to tell the protocol of knowing which staff would handle incidents and which would monitor the kids.

Correction Narrative: Staff were interviewed and able to tell the protocol for ensuring children are supervised should an incident occurr.


raw_content: Through interviews, it was determined that two units were out of ratio having 20 residents with 2 staff and 11 residents with 2 staff.

Correction Narrative: Walk through was completed and ratio was in compliance.


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

raw_content: Based on documentation and interviews with staff, it was determined that the operation is changing the staffing schedules and adding more staff and are providing licensing different schedules.

Correction Narrative: Staff were interviewed regarding schedules and were found in compliance.


summary: 748.309 - Reporting Serious Incident - All serious incident reports to Licensing must be made to the Texas Abuse & Neglect Hotline

raw_content: Through interviews with staff, it was determined that the operation is completing incident reports but are not making reports to the hotline.

Correction Narrative: Spoke with staff and they were able to give the protocol for documenting and reporting Serious Incidents.


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

raw_content: Through interviews with children and staff, it was determined that staff are cursing directly at children to get them to comply.

Correction Narrative:
Several children were interviewed and described punishment as having a meal on the unit if they are not allowed to go to the cafeteria. All stated they get plenty of food.
An email was received from the operation. Senior Leadership Director's have been notified of the issue of staff using profanity around patients.  Human Resources has been contacted to have training added to HealthStream for all direct care staff in Speaking Respectfully to Patients and  Standards of Professional Conduct.  Patient Advocate and Senior Leadership will conduct follow-up interviews with patients and staff members to ensure that staff are speaking in an appropriate and therapeutic manner to patients and to other staff members.  Staff that are not using appropriate language are receiving training and disciplinary actions to correct the issue.


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: Review of the documentation and CLASS verified it was made known a child had a serious injury on 12/5/23 but the Hotline was not notifiied until 12/11/23.

Correction Narrative: Interviews and walk through completed for new protocols on Serious Incident reporting.


summary: 748.3365(c)(3) - Bedding-must provide each child with clean bed linens once a week or as needed for cleanliness; linens changed/laundered if used by different child

raw_content: During the course of the investigation several staff stated children would wet their beds and not get clean sheets. There was a bedroom observed during the walk through with soiled linens.

Correction Narrative: Director of Plant Ops, Campus Administrator, Housekeeping Supervisor, and Director of Nursing/Interim Program Director are performing daily checks of the units for cleanliness.  Housekeeping Supervisor has implemented janitorial logs for each unit that state what cleaning services was done on the unit that day.  Director of Nursing/Interim Program Director has retrained nurses and MHT's that they are to ensure that all bedding is clean.  Any bedding that is soiled is changed out immediately and new clean bedding placed on patient beds. Senior leadership are spot checking rooms and units daily to ensure that the units are clean, and that staff have signed the checklist verifying that they have a clean unit.  Communication of unit cleanliness will be discussed in daily flash meetings and in weekly unit meetings.


raw_content: Throughout the course of the investigation multiple staff and children admitted that staff use profanity around the children.

Correction Narrative:
Senior Leadership Director's have been notified of the issue of staff using profanity around patients.  Human Resources has been contacted to have training added to HealthStream for all direct care staff in Speaking Respectfully to Patients and  Standards of Professional Conduct.  Patient Advocate and Senior Leadership will conduct follow-up interviews with patients and staff members to ensure that staff are speaking in an appropriate and therapeutic manner to patients and to other staff members.

2/27/24 an Unannounced Inspection was conducted and staff were interviewed and validated they have been spoken with about how to speak with residence and there is training's on their portal.


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

raw_content: During the walkthrough trash was observed throughout the walkthrough of Liberty Hall.

Correction Narrative: Director of Plant Ops, Campus Administrator, Housekeeping Supervisor, and Director of Nursing/Interim Program Director are performing daily checks of the units for cleanliness.  Staff (MHT's and Nurses) have been retrained that the expectations are that there is to be no food in patient rooms, rooms are cleaned, and items picked up off the floor in bedrooms, and trash is to be picked up on units.  Cleanliness of rooms and the unit has been added to the staff assignment checklist which is signed off on daily.  Senior leadership are spot checking rooms and units on a daily to ensure that the units are clean, and that staff have signed the checklist verifying that they have a clean unit.  Communication of unit cleanliness will be discussed in daily flash meetings and in weekly unit meetings.


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

raw_content: During the walkthrough of the operation a child was observed in his room alone with no caregiver within visual or auditory range of the child.

Correction Narrative:
PI/Risk Management Analyst immediately addressed the supervision issue with the staff member responsible for the patient while on the unit during the walk-thru with licensing.  All direct care staff were trained in October 2023 with the Patient Safety Observation training module video series with documented attestation of the training in the employee personnel files.  All new staff have been trained in Patient Safety Observation Rounds during new hire orientation with documented attestation of the training in the employee personnel files.  The staff member was re-educated on Patient Safety Observation Rounds training protocols.  This training specifically outlines patient supervision requirements, patients are not left alone in patient bedrooms during the programming day, patient bedrooms are locked during the programming day, and patients are to use the community bathroom during programming hours.

2/27/24 An unannounced inspection was conducted and all children were being supervised appropriately.


summary: 748.1005 - Child/caregiver ratio-Each group must have enough caregivers for that group who are not caring for other children or doing administrative work

raw_content: Throughout the course of the investigation multiple staff admitted to the operation being out of ratio. Nurses at the operation were working as direct care givers and as nurse at the same time while being counted in ratio.

Correction Narrative:
All staff have been trained that if they become aware of a ratio issue that they are to notify their immediate supervisor, Program Director, and/or Director of Nursing so that the ratio issue can immediately be addressed.  If a nurse is counted in ratio and responsible for patient care, then prior to the nurse performing nursing related duties, the nurse will notify their immediate supervisor or DON so that a staff member can replace the nurse during that time so that ratio is maintained.  Shift Hound is being monitored daily by the Director of Nursing/Interim Program Director to ensure that ratios are maintained and any areas that need staffing are addressed timely.

2/27/24 Inspection was conducted at the facility and they were observed to be in compliance with ratio.


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

raw_content: A caregiver yelled at a child in an untherapeutic way after the child had run away from the operation.

Correction Narrative: Received and reviewed documenation with staff's signature showing the staff was retrained.


raw_content: An unsafe environment was created when all staff intervened in one incident leaving other children with previous physical altercation issues unsupervised allowing a third altercation between the two children.

Standard Number / Description: 748.685(c)(2) - Caregiver responsibility - provide a safe environment


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

raw_content: In the course of the investigation it was found a staff member left the key to all doors accessible to a child in care allowing them the opportunity to elope from the facility.


raw_content: In the course of the investigation it was determined staff was doing other duties and was not aware of the childrens' actions allowing them to leave the premises.

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


raw_content: A child went to the emergency room on 8/19/23 after having a seizure. Another child went to the emergency room on 9/17/23 after having a seizure. Another child went to urgent care on 8/12/23 for a fractured finger. These incidences were not reported to Licensing.

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


raw_content: During the walk-through of Eagle unit located in Liberty Hall, it was noted that one child s pillow was complete stained and had red circular stains on it. Please refer to 748.3015, if applicable.

Standard Number / Description: 748.3365(c)(3) - Bedding-must provide each child with clean bed linens once a week or as needed for cleanliness; linens changed/laundered if used by different child

Correction Narrative: As per the Administrator/Director of Risk Management, Director of Performance Improvement, & Facility Compliance Officer, the direct care and housekeeping staff have been notified about the concern. The bedding was changed out and staff will be more diligent in inspecting pillowcases to ensure that they are clean and freshly washed. The wash schedule for the patients is on a weekly basis. Staff will ensure that clean linens are available, as necessary.  One note is that no linens were used by more than one patient.  All linens are stripped after a patient discharge and laundered to ensure the highest level of cleanliness and sanitation.


raw_content: It was determined that Bunk House was out of ratio, 17:2, for more than 15 minutes as one staff was in the Nurse s station conducting administrative duties and speaking to children individually, and another staff left Bunk House to drop off her personal items in the Admin building. A nurse was in the Med room performing medication/administrative duties.

Standard Number / Description: 748.1005 - Child/caregiver ratio-Each group must have enough caregivers for that group who are not caring for other children or doing administrative work


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

raw_content: It was documented and made known that a child was not adequately supervised as they were able to open locked doors, leave the unit and climb the buildings roof multiple times without staff being aware he was absent from the unit. It was also recorded that the child was able to leave the unit and jump the propertys fence in which resulted in injuries.

Correction Narrative:
As per the operation's Administrator, the operation will ensure that all staff remain in close proximity of all patients who display elopement tendencies.
1/9/23 Met with Administrator, Director of Nursing, Program Manager, and Risk Manager the facility will now have the child at the Oasis, off the Unit, with a MHT. If the child must remain on the Unit a MHT will be placed with them to prevent having nurses to fill in.
RCCR Inspector also observed children walking from different areas of the campus to school and all were in ratio.


summary: 748.535(3)(F) - Child-care administrator responsibilities-Ensuring that operation complies with applicable rules of chapter 748 and other applicable rules and laws.

raw_content: It was confirmed that a memo had been provided to all staff noting no staff member shall contact any outside entity without prior communication with a program supervisor, manager, and/or Director regarding any ratio related concern. All staff members confirmed that they have been directly told not to speak to Licensing and/or provide information. It was also reported that all incidents are to be reported to the nurses and they will inform the administration to be advised whether or not the incident is to be documented in the operations system.

Correction Narrative:
As per the operation's Administrator, the operation emailed staff on 12/11/2023 clarifying the intent of the Memo previously distributed. It has been clarified that the memo referenced a procedure that was related to the operation and corporate compliance and was not related to reporting to the hotline or speaking to licensing.  The clarification also clearly stated that the operation trains staff on how to report to regulatory and are encouraged to report incidents and cooperate with licensing investigations should they occur. The email sent also states that if staff have any questions or concerns, then they are welcome to contact the Administrator as they are the Director of Risk Management and Performance, and the operation's Facility Compliance Officer.  It should be noted that incident reports are submitted by the Nurse on duty.  Staff are free to report incidents as necessary, but the incident report is submitted to our database by nurse on duty as that is how our database is set up by the operation's corporate. The memo and the email sent to staff was provided by the operation.
Administrator has clarified with all staff that they are allowed to report to the hotline, but to allow the operation the oppurtunity to correct a concern. Ex. A staff does not show, notify the DON or Program Coordinator and they will have someone come over immediately or fill in themselves until a staff can arrive.


summary: 748.3319(a) - Required Postings-Residential Treatment Center's must have

raw_content: Operation did not have required No Trespassing signs posted at entrance of facility.

Correction Narrative:
Original compliance date was 10/10/23. Operation ordered signs from HHSC and as of 10/9 they have not received yet. Extension granted until 11/6/23. Anita Orr
On 10/9/23 Inspector Orr had extended the compliance to 11/6/23. At this time the signs have still not arrived, but Glenn Scruggs (Administrator) was able to verify they had been ordered. Per Supervisor Leon the etension will be found compliant. MLayton


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

raw_content: 10 of 10 serious incident reports were reviewed and none documented the operation's address or phone number, or the child's date of admission as required.


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

raw_content: Caregivers conducted an unwarranted restraint on a child in care as the child was running away.

Category: Emergency Behavior Intervention


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

raw_content: Two staff files were reviewed for EBI training documentation and both were missing documentation verifying annual EBI training was completed.


summary: 748.833(a)(2) - Orientation exemption-Ensure required abuse/neglect training has been completed in the past 12 months.

raw_content: Three out of ten staff files reviewed were missing the signed policy related to reporting abuse and neglect.

Category: Training and Professional Development

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


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: During the inspection, two of six child files reviewed did not identify the level of observation required in the preliminary service plan.


summary: 748.1337(b)(1)(D)(ii) - Initial Service Plan-Include instructions to caregivers about level of supervision required

raw_content: In reviewing the Initial Service Plan there was no direction on supervision provided.

Correction Narrative: Received a copy of the new form for Service Plan. An area has been added for High Risk Behaviors and instructions to staff. Mlayton


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: During the investigation, documents reviewed show the census and staffing schedule show several days in February where the Hacienda unit was out of ratio.

Correction Narrative:
An email from the operations LCCA, Glen Scruggs, was received stating the following :

Regarding 748.1003 (a) and 748.535 (3)(A)

I have addressed the staffing concerns with Program, Human Resources, and Nursing Directors.  Meridell is continuing to hire MHT's and Nursing staff so that we can develop a true PRN pool that is available when a staff member calls in sick or is scheduled to be out on PTO.  I just taught a New Employee Orientation Class that included 13 MHT's and 2 Nurses.  We have another New Employee Orientation Class that begins on 4/24 as well.  We plan on continuing to hire so that we always have a pool of staff ready when staffing needs change.  We are also reviewing shift hound daily to plug any areas of concern so that all shifts are covered and remain in ratio.  I am communicating with Program Director, Nursing, Human Resources, and CEO when any concerns are brought to my attention regarding potential ratio concerns so that they are addressed immediately to ensure that ratios and staffing patterns are maintained.


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

Deficiency Narrative: During the investigation, documents reviewed show the census and staffing schedule show several days in February where the Hacienda unit was out of ratio.


summary: 748.930(b)(2) - Annual Training- Caregivers must have 2 hrs trauma informed care.

raw_content: 7 of 8 direct care staff files pulled are missing 1 or all of the annual required trainings: Normalcy, Trauma Informed Care and EBI

Correction Narrative:
An email from the operations LCCA, Glen Scruggs, was recieved and stated the following : Regarding 748.930 (b)(2)
All active staff have completed the required trainings.   Human Resources has created a monitoring schedule to ensure that these specific trainings are tracked so that employees do not lapse on their training.


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

raw_content: During the inspection, it was found that the Administrator doesn't have a background check under this operation.

Correction Narrative:
The background check for the individual providing assistance from the sister company has been run under this operation.

On 2/3/23, the operation also emailed and reported their current process for running background checks for new hires is listed below. These steps are completed for ALL employees, contractors and anyone on the campus that has direct or indirect involvement with children:
	All employees are submitted through the Texas Health & Human Services Child Care Licensing (form that is filled out and submitted by HR attached)
	They also use a standardized program, PreCheck, that verifies positive identification of the individual, maiden/alias search, employment verification, education verification, sex offender registry list, national criminal history, statewide criminal search, county level criminal history, and SanctionCheck screening (form outlining the process is attached)
	PreCheck transport package is also submitted for anyone operating a vehicle or transporting children.

They reported moving forward they will request background checks from facilities for any employees they share or will request new background checks.


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

raw_content: Six out of six child files reviewed did not have documentation showing two weeks advance notice to the parents for the initial service plan.

Standard Risk Level: Low

Correction Narrative:
CEO provided the following plan:
i.	Change 10-day requirement for Master Treatment Plan staff meeting to 14 days and conduct Master Treatment Plan Review at time of 14-day staff meeting
ii.	Letter of invitation will be provided in person or via email to parent or family of child within 24 hour period of admission
iii.	Est completion January 18th, 2023


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

raw_content: During the inspection thirteen out of sixteen bathrooms had mildew.

Correction Narrative: This concern has been resolved.


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

raw_content: Five  mattresses in seventeen rooms inspected had torn mattress and mattress covers. One of the mattresses was being used by a child and it was replaced at the time of inspection.

Correction Narrative:
CEO provided the following plan:
i.	All mattresses on campus that had a tear in the mattress, or the cover have been replaced as of 12/21/22 with mattresses that fit the requirement of this standard.
ii.	The Maintenance department will conduct monthly environment of care audits to ensure that all mattresses/covers are in good repair and will replace one if it does have a torn mattress/cover.


summary: 748.1437(1) - Discharge/Transfer Documentation-Must include date and circumstances of discharge or transfer

raw_content: Four out of four discharged child records reviewed failed to include the circumstance of the discharge.

Correction Narrative:
The CEO provided RC with a plan noting the following:
Modify Discharge Summary to include text box and/or check boxes identifying circumstances of discharge (e.g. safety concerns, discharge status, recommendations for level of care, specific changes to living environment, treatment providers, community care providers, support systems)                                                     ii.           Medical Records manager to modify Discharge Summary PDF accordingly                                                   iii.           Discharge Summary will be filed in Discharge Tab of the child record                                                  iv.           Est completion January 18th  202


summary: 748.1337(b)(1)(D) - Initial Service Plan-Include specific goals and strategies to meet the child's needs, including instructions to caregivers

raw_content: Six out of six child records reviewed failed to incorporate individualized and specific goals or instructions to caregivers how to accomplish those goals.

Correction Narrative:
CEO provided the following plan:
i.	On Master Treatment Plan, Therapists will include Parenting Strategies on every Treatment Plan.
ii.	Therapist will meet with family during family therapy session to identify specific, individualized goals and interventions on how parent(s) will meet the need of the child
iii.	Est completion January 18th, 2023


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: Four out of ten child records did not list the known allergies or chronic conditions in a prominent place on the child file and one child record reviewed did not list a medication allergy.

Correction Narrative:
The CEO provided the following plan: i.	Admissions will continue to send emails with patients admitting to unit with information that includes any and all medication, food and other allergies included. Admitting nurse will verbally relay information, which will include all allergies including ones stated above, to the receiving/unit nurse.
ii.	The admissions nurse or unit nurse with transcribe all allergies to the allergy chart sticker/indicator and place it on the bound side of the chart for quick reference.
iii.	If no allergies are noted upon admission, NKDA will be indicated
iv.	This will be audited and noted during supervisory rounds which take place weekly by administration. If no allergy sticker is observed then the auditor will notify the unit nurse immediately and reported to the DON.
i.	Admissions will continue to send emails with patients admitting to unit with information that includes any and all medication, food and other allergies included. Admitting nurse will verbally relay information, which will include all allergies including ones stated above, to the receiving/unit nurse.
ii.	The admissions nurse or unit nurse with transcribe all allergies to the allergy chart sticker/indicator and place it on the bound side of the chart for quick reference.
iii.	If no allergies are noted upon admission, NKDA will be indicated
iv.	This will be audited and noted during supervisory rounds which take place weekly by administration. If no allergy sticker is observed then the auditor will notify the unit nurse immediately and reported to the DON.


summary: 748.1339(c) - Initial Service Plan-Child & parent must be invited to meeting to develop service plan & discuss participation in childhood activities

raw_content: Six out of six child records reviewed did not document an invitation for the parent or child to participate in the development of the service plan.

Correction Narrative:
Plan provided by CEO states te following:
i.	Create letter to invite families via email and notify of child inclusion in Staffing/ Treatment Plan Review 14 days prior to scheduled Staff meeting
ii.	Using the Master Treatment Plan, review schedule for each unit to identify what children are due for review
iii.	Therapists will be responsible for emailing letters to identified families by 14 day advance deadline
iv.	Letter will be placed in child record as proof of invitation to include family and child in staffing and Treatment Plan Review
v.	Therapist will be responsible for notifying child of invitation and right to attend staffing and treatment planning review
vi.	Therapists will document on Treatment Team Staffing signature page if child and/or family refusal
vii.	Est. completion January 18th, 2023


summary: 748.1331(b)(4) - Preliminary Service Plan-For child receiving treatment services, identify any issues or concerns child may have that could escalate child's behavior

raw_content: Six out of six child records reviewed did not include issues that could escalate the child in cares behavior in the preliminary service plan.

Correction Narrative:
CEO provided the following plan:
i.	Confirm with Director of Nursing (DON) where Crisis Safety Plan is documented in child's record
ii.	Request medical records file document in Treatment Planning Tab
iii.	Crisis Safety Plan includes patient identified behaviors  will be attached and filed to Initial Treatment Plan AND filed accordingly
iv.	Est completion January 18th, 2023


summary: 748.949(b)(4) - Annual Training Documentation-Includes the trainer's name and qualifications, or the source of the training for self-instructional training

raw_content: 3 of 5 staff's certificates submitted for review, specifically in regard to SAMA, did not have the trainers' qualifications documented.

Correction Narrative: The CEO emailed the safety plan that was put in place regarding lowering capacity temporarily and having all staff trained prior working on the floor.  The email included their decision not to administratively review the findings at this time.


raw_content: During the investigation, it was determined the operation was not in compliance in regard to ratio on numerous occasions the last month and a half. Specifically, the operation was out of compliance 19 times out of a 16 day time period.


summary: 748.1011 - Child/caregiver ratio-Includes only qualified caregivers working directly with a child or group of children

raw_content: During the investigation, it was determined the operation was using unqualified employees as caregivers on the unit due to staffing shortages. These employees were not properly trained in SAMA, normalcy, and/or trauma informed care. 8 staff training records were reviewed. 6 out of 8 records did not have proper SAMA training, 2 out of 8 records did not have normalcy training, and 3 out of 8 records did not have TIC training.


raw_content: During the course of the investigation, it was determined that caregivers are not following the child/caregiver ratio expectations on a regular basis.  It was noted 1-2 caregivers are left to supervise up to 17 children.

Correction Narrative: RCCR Inspector Stockton spoke with the Administrator about the ratio concerns.  The Administrator acknowledged the concerns around ratio and provided a written plan email discussed the staffing needs which includes the placement acceptance rate at this time.


summary: 748.113(8) - EBI policy - Training for emergency behavior intervention

raw_content: During the course of the investigation, it was determined that caregivers reported they were unsure how to handle the emergency situation and did not have proper training.

Correction Narrative:
The operation (CEO) has sent a plan to ensure caregivers are trained in EBI and all other required trainings prior working directly with children in care.  Specifically, the CEO indicated staff would be trained as caregivers regardless of their title.

An in person follow up was also completed on 12/6/22 and the CEO indicated both verbally and via email that he would not be seeking an administrative review for this citation.


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: During the course of the investigation, it was determined a child in care was physically abused by a caregiver when he was choked.

Correction Narrative: The operation handled this situation appropriately and are responsible for ensuring parent notification is complete within 10 days of being notified that a caregiver has an RTB.


summary: 748.303(a)(11)(A) - Serious Incident-Report to Licensing no later than 24 hours after awareness that a child contracts reportable communicable disease

raw_content: A child in care tested positive for a communicable disease on 7/10/22, the illness was not reported until 7/12/2022.

Correction Narrative: Administrator stated the are adding a check box to call the hotline to their COVID reports so that in the event that he is not present as in this case the staff will know to call.


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: During the course of the investigation it was determined an incident requiring medical attention was not reported timely.

Correction Narrative: Received email from Douglas Flannery (Compliance Manager/Administrator) stating they had failed to report timely and now have all nurses sign an attestment that states the protocol for reporting to the hotline and how to report. MLayton


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

raw_content: During the investigation it was made known that a staff member calls the children in care "tubby tubby" and "ugly".

Correction Narrative: The staff involved was given a written warning as a corrective action and it was placed in the staffs record.


summary: 748.3365(a) - Bedding-must provide each child with an individual bed or bunk bed in child's room that elevates mattress off floor, or crib as appropriate

raw_content: Based on preponderance there is evidence that children have slept on the hall floor on an unelevated mattress.

Correction Narrative: Director of risk management sent an email stating they were "Researching the purchase of a safe product to have available on each unit in the event a patient meets the criteria for increased supervision at night." Inspector sought clarification to see if he was referring to some sort of cot, he replied with that was correct and that it is hard to find a safe, storable, option.


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

raw_content: It was discovered during investigation a staff member shoved a child in care during a verbal discussion. The video footage showed the incident to be valid. Compliance was completed at time of inspection.


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

raw_content: A child in care was to receive follow-up within 1 week from 1.16.22. No follow-up was completed.

Correction Narrative:
Additional follow up info received 3/31/22
Mr. Flannery stated if this happens again they will schedule the follow up and incur the cost.

Operation sent the following plan
This is a very uncommon situation.  Usually guardians are very cooperative with us when coordinating any type of appointment. We did diligently make several attempts to get the orthopedic appointment scheduled.
Going forward,

Leadership will assure that contact notes will be added to the medical record to document attempts to collaborate with guardians regarding appointment.   In cases where guardians are resistant, we will have documentation of our attempts and barriers.


summary: 748.303(a)(10)(A) - Serious Incident-Report to Licensing no later than 24 hours after awareness that a child contracts reportable communicable disease

raw_content: When reviewing documents, it was determined that at least one child tested positive for COVID and was not called in on time.

Correction Narrative: Doug Flannery emailed me and let me know that they provided education to all nursing staff regarding reporting and created a call tree of reporting to assure all reports were timely.


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

raw_content: It was determined that a child in care had a fractured hand on 9/3/2021. This was not reported to RCCR until 9/7/2021.

Correction Narrative: Upper management addressed this standard with the staff member involved. There also will be a in-service training addressing reporting standards.


raw_content: A staff member was observed on video to swing and hit a child in care multiple times, wrestled with the child and placed the child in an improper restraint where the child appeared to be knocked to the ground and have the staff member's arm across their neck.

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

Correction Narrative: The staff member involved in this investigation was terminated prior to DFPS initiating the case.


summary: 748.2605(b)(1) - Personal Restraints Prohibited-Prone and supine restraints except as a transitional hold that lasts no longer than 1 minute

raw_content: A caregiver was observed on video placing a child in care in a supine restraint that lasted over 4 minutes.

Correction Narrative: The staff member involved in this investigation was terminated prior to DFPS initiating the investigation.


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

raw_content: Several nurses were observed on video to not intervene when a child was placed in a supine hold and when another caregiver was hitting a child. They also did not continuously observe the child during the restraint to ensure safety and were observed leaving the room multiple times leaving the escalated caregiver alone with the child.

Correction Narrative:
The following response was received from the operation:
At Meridell Achievement Center we run a medical model where there is a nurse for each unit on each shift who is in charge of that shift. All nurses at Meridell will be retrained to ensure they know the proper procedure for intervening in situations where staff are escalated, or safety protocols are not adhered to. They will all sign an acknowledgement to this effect.
An unsigned copy of the aforementioned acknowledgement was provided.


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: The video of this incident showed that a caregiver got in a child's face for about 18 seconds and did not make any attempts to de-escalate the situation. The child also had stopped the destructive behavior when the caregiver walked into the room so the EBI use may not have been necessary.

Correction Narrative: The staff member involved in this investigation was terminated prior to DFPS initiating this investigation.


summary: 748.2551(b)(2) - EBI Implementation-The caregiver must consider the permitted types of emergency behavior intervention

raw_content: A caregiver was observed on video using an improper restraint that was not a permitted technique allowed by the operation.


summary: 748.2101(2) - Medication Storage-Keep medication inaccessible other than to employees responsible for stored medication

raw_content: The medication room door was broken and staff did not ensure it was properly closed and a child was able to enter the room and obtain and ingest OTC medication.


facility_name: Bridge Emergency Shelter

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

raw_content: Exterior wall, that is accessible to children in care, had significant mold.

Correction Narrative: In person follow-up conducted confirmed that exterior wall was cleaned and repaired.


summary: 748.1109(b) - Child Rights sibling contact-Address plans for sibling visits and contacts in the child's record

raw_content: A child's record did not contain plans or contact information for their siblings.

Category: Children's Rights

Correction Narrative: The operation provided a compliance plan by email. Operation states that all shelter team leads, direct care workers, behavioral support staff, campus manager have been provided with training concerning the need to have youth in care siblings contact information documented. Each type of intake has been visited on how at intake sibling information will be collected for DFPS, RHY and BCJP youth. Upper management will also continuously check on this moving forward and has stressed this fact with the overnight staff who do the majority of the RHY intakes.


summary: 748.311(4) - Serious Incident Documentation-Includes names of all adults involved and their role in relation to the child(ren)

raw_content: The incident report only had the names of two of the staff involved. There were others not listed.

Correction Narrative: The operation provided a compliance plan by email. Operation has taken corrective action by completing a staffing with lead staff to review requirements for serious incident reports. This information was then disseminated down to all staff.


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: It was found that one childs prescribe medication was administered to another child.

Correction Narrative:
Email: Operation provided a corrective action plan on 02/24/2025. Staff that incorrectly administered medication has been placed on supervised medication administration until end of March 2025. Team leader, program or campus manager or nurse will supervise this staff member during medication duties. All staff will be provided with additional medication management training. Staff on duty and responsible for medication error will meet with nurse within 24 hours to discuss error and complete report/documentation. The error report will be completed before staff leaves shift.

Inspection: An inspection was completed at the operation on 03/19/2025. One staff and one child was interviewed and medication logs were reviewed. No concerns were found during this inspection.


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

raw_content: A medication error report was not completed within 24 hours.


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

raw_content: Multiple children in care allege the same staff uses profane language with them and that staff claimed there may have been times when the children in care overheard such language.

Correction Narrative:
Email: On 03/07/2025 the operation provided a corrective action plan by email. Operation states that they will include the following topics in staff meeting agenda: a. Supervisor will work directly with the Team on different trauma informed therapeutic TBRI approaches to embrace other than foul language. B. Utilize BSS Team meetings to discuss concerns, approaches, and support to continue growing as a team and provide the mentoring skills and leadership   qualities this position requires for keep children and staff safe in a non-violent environment. C. A clear understanding of the Mission and Core Values of RMYA will be reenforced at each meeting, such as Protection, Responsibility, Community, and Integrity. Helping the Team to understand these are values that they should always reflect as they live out the Mission of RMYA to break the circle of abuse.

Inspection: A follow-up inspection was completed at the operation on 03/19/2025. One staff member and one child were interviewed. No concerns were found during the inspection.


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

raw_content: The operation completed a preliminary service plan four days after admitting a child in care.

Correction Narrative:
Email: On 03/07/2025 the operation provided a corrective action plan by email. Operation states that in the future the clinical team will gather to assess if there are any service plans coming due over a holiday time, long weekend, or any period where the clinical team might be away from the Family Resource and Counseling Center for several days. During these times there is always a clinician on-call. The corrective action will be that should a service plan be due while they are off it will be assigned to the on-call clinician to come in and do it or complete it via telehealth making sure all service plans are completed on time.

Inspection: A follow-up inspection was completed at the operation on 03/19/2025. One staff member and one child were interviewed. No concerns were found during the inspection.


raw_content: Staff who was not authorized to use emergency behavior interventions due to not completing training was involved in demonstrating behavior intervention techniques with another staff which should never be used unless in an emergency situation.

Correction Narrative:
Our corrective action is as follows:
1)	The Training Director has sent out an email to all instructors informing them that at the start of each HWC training class and through the session, instructors will mention to trainees that they are only to practice holds with an approved instructor at all times. That they are not to practice on children or in the sight of children. Director of Training sent an email to all Handle with Care Instructors on 03/28/24. 	We never practice HWC with residents. Practicing HWC techniques is only done with colleagues, and preferably, with a HWC instructor present.
 We never allow the residents to see a HWC class or us as staff practicing HWC

2) The team leader on each shift will make it a part of shift change to inform new staff doing training shifts that they may not touch a child until they have been through pre-service and completed their HWC training. That this will only take place when they have been approved to be in ratio on shift and only in the case of a child wanting to harm others or self. They will record this in their shift change notes.


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 provided Annual Summary Log was missing entries for unauthorized absences occurring in March 2023 and did not contain all required information noted in 748.453 (a) (1-6).

Correction Narrative: A compliance response was received from the operation on 12/12/2023. Operation stated that they have created a new spreadsheet to track information on runaways. They will use this spreadsheet as a log of their runaways throughout the year.


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

raw_content: Child in care was given the wrong medication in error.

Correction Narrative:
On 10/10/2023 a follow-up inspection was completed at the operation. Administrator was present and provided a follow-up plan. Training regarding medication administration was provided to all staff members. Training log was provided by the operation. Staff member that involved in the incident was put on a corrective action plan and provided with additional training.

Administrative review of this deficiency was waived by the operation.


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

raw_content: Identified high risk behaviors do not include plan to address the risk for child in care.


raw_content: During the review of a child s medication record it was notice that the child did not receive their  PM dose of medication as prescribed.

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

Correction Narrative:
Email received from operation on March 16,2022. In regards to inspection conducted by Heightened Monitoring Inspector on March 7,2022.
Response:
In response to Administrative Rules or Minimum Standard rules which were inspected on 03/07/22:
Others: 748.2003(b)(5)

Our response:
The following has been re-implemented:
1.The supervisors on shift at the Bridge Emergency shelter, in addition to double counting medication before administration, will ask for another staff member to be present when prepping medication.  This will allow for uninterrupted time and focus on the medication administration.
2.The Shelter's Program Administrator will assign triple counting to the overnight staff.
3.This was discussed amongst the leadership team on 03/08/22.
In addition to this, the employee who failed to administer the medication was also disciplined.


summary: 748.1205(a)(7) - Admission Documentation-Includes child's immunization record

raw_content: Two child files reviewed did not contain vaccination records.

Correction Narrative: An email was received from the operation with the missing immunization reports attached. The operation will continue to complete quarterly audits to catch any issues with record keeping.


summary: 748.981(c) - First-aid-CPR training-Any new caregiver not currently certified in first-aid must be trained and certified within 90 days of employment

Correction Narrative:
Standard: 748.881(7) 748.981(c) First-aid-CPR training-Any new caregiver not currently certified in first-aid must be trained and certified within 90 days of employment (Weight: Medium High)
Specifics:  First Aid and CPR training was completed 22 days after the required date.
Response: RMYA seeks to provide services for youth that are of the highest professional quality.  In order to ensure this Pre-service training has been extended to a 7-day training to ensure the needed training is covered.


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

Correction Narrative:
Standard: 748.311 Serious Incident Documentation-Documented in written report. (Weight: Medium)
Specifics:  Serious incident report was not updated with additional information.
Response: RMYA seeks to maintain a level of the highest professional quality.  In doing so, pertinent information on an employee involved in a serious incident will be kept separate.  The needed information will be kept in a section of the HM monitoring binder.


summary: 748.881(7) - General pre-service training curriculum-Includes normalcy

raw_content:
The required normalcy training was not completed during pre service train
ing.

Correction Narrative:
Standard: 748.881(7) General pre-service training curriculum-Includes normalcy. (Weight: Medium)
Specifics:  The required normalcy training was not completed during pre-service training.
Response: The topics covered in pre-service, including Normalcy, are covered in pre-service training.  The Program Administrator will ensure their employee files have the needed certificate(s).  The Training Director will ensure the training obtained in pre-service are documented with a certificate(s).  The employee's monitored file has a certificate in place.   Pre-service training has been extended to a 7-day training to ensure the needed training is covered.


summary: 748.931(a)(1)(B)(iii) - Annual Training-Every 6 months a caregiver must complete at least 4 hours of training in EBI

Correction Narrative:
Staff member completed two EBI training classes since inspection, each being 2 hours long.  Inspector formed completion at HM inspection by reviewing the class sign in sheets and certifications.
Standard: 748.931(a)(1)(B)(iii) Annual Training-Every 6 months a caregiver must complete at least 4 hours of training in EBI. (Weight: Medium High)
Specifics:  4 hours of EBI training was not completed within the 180 day of last completed EBI training.
Response: The employee in question completed the 2 hours of EBI training on 10/07/2021 and will complete 2 more hours on 10/28/21.  The Program Administrator should check their staffs training monthly to ensure they are on track for their training hours, and up-to-date with all pre-service/90 day/bi-annual/annual training requirements.  Handle with Care training (verbal de-escalation, self-defense, and personal restraint techniques) is essential training to maintain a safe environment at our programs. Sign in sheets/certificates for training on 10/07 and 10/28 will be turned in to HM Monitor the following visit during the week of 11/01/21.


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: A staff member failed to return a child to the operation and instead transported the child to a different location.

Correction Narrative: The operation responded to the deficiency by stating that staff who receive information on runaways must report to their supervisors. A staff member is obligated to report this information even if a runaway makes contact with a staff member outside of their working hours. The incident in question and corresponding citation will be reviewed with all Bridge staff on December 16, 2021 and agency wide from December 14th through December 15th.


raw_content: EBI training was completed 9 months a part which does not meet the required every 180 day timeframe.

Standard Number / Description: 748.931(a)(1)(B)(iii) - Annual Training-Every 6 months a caregiver must complete at least 4 hours of training in EBI

Correction Narrative: Administrators have been asked to run a bi-weekly training report to align with staff scheduling (to ensure staff availability to attending trainings), as well as a monthly training reports.


summary: 748.3443(b)(1) - Food Preparation-Must have a thermometer in refrigerators & store refrigerated food at 40 degrees Fahrenheit or below

Correction Narrative:
A refrigerator observed in the kitchen was at 44  degrees farenheit.

Standard was evaluated and found to be compliant.


raw_content: A staff member was found to have conducted an inappropriate physical intervention on a child in care as well as making demeaning comments to the child. Another staff member witnessed the inappropriate physical intervention and failed to intervene to stop or de-escalate the situation.

Correction Narrative: Follow up was received from operation. On July 08, 2021 minimum standards regarding children's rights was discussed in a staff meeting. Issues regarding demeaning comments will be addressed in agency-wide staff meetings during week of July 13th through 15th. Employees will also review policy and procedures on behavior intervention, specifically authorized restraint techniques. This will be addressed in an agency wide meeting during the week of April 13th through 15th. The employee involved in the incident was immediately placed on administrative leave. The employee has since resigned from the operation. An administrative review was requested by the operation.


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

raw_content: Video footage shows staff run out to chase a child and left behind two children unattended.

Correction Narrative: A response to the investigation was received from the operation. Policies and procedures will be reviewed in a staff meeting on 08/03/2021- 08/04/2021 with a focus on remaining calm.


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

raw_content: Video footage provided shows a staff member placed a child in an inappropriate restraint.  The staff member is seen placing their arms underneath the child's armpits and brings their hands behind the child's head. They are also seen lifting the child slightly off the ground to walk them to the door as the child is restrained.

Correction Narrative: A response to the investigation was received from the operation. The operation will review EBI procedures to ensure compliance with standards. Additionally, the employee involved is on administrative leave and if they return they will be given an assignment within the guidelines of the provisional status.


facility_name: L'Amor Village Emergency Shelter

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 the inspection, it was found that there were two chairs located in the common living area being used by children in care. The chairs had cuts on the leather thereby exposing the filling under it.

Correction Narrative: The chairs have been repaired.  Please see the attached photos.


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

raw_content: During the inspection, it was found that the flooring in 3 bedrooms, common living area, and in the kitchen was peeling and in a state of disrepair. There was also an exposed nail around the siding of the house.

Correction Narrative: In room #1 carpeting has been put down, room #2 the flooring has been pulled up and replaced, room #3 the missing tile has been installed.  Please see pictures.:  The nail has been removed.  Please see photo.


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

raw_content: During the inspection it was discovered that one out of four serious incident forms reviewed did not contain a description of the nature of the incident as well as the names of the witnesses to the incident.

Correction Narrative: The Document has been corrected by adding word prompts for staff members to better describe the incident's nature, cause, techniques used to deescalate, and the outcome and solutions. Also, an area has been added to include the names of individuals that witnessed the incident. Please see attached document.


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

raw_content: During the inspection, it was discovered that the AWOL Summary Log form was missing information regarding the gender of the child involved.

Correction Narrative: The word Gender has been added to the Awol Summary Log.  Please see attached document.


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

raw_content: During the inspection, it was discovered that the operation's fire inspection was expired.

Correction Narrative:
The follow up date is 05/08/2025.
The follow up method is email.
The extension request is approved on 05/08/2025 by RCCR Inspector Ibrahim Fye.

05-09-2025-IF- The operation emailed RCCR Inspector Ibrahim Fye a copy of the newly completed fire inspection dated 05-09-2025.


summary: 748.4007(8) - Overnight Excursion-Each vehicle must have an operable flashlight

raw_content: Vehicle used to transport children was not equipped with a flashlight.

Category: Transportation


summary: 748.4083(a) - Vehicle and maintenance-Must maintain a vehicle in a safe operating condition at all times

raw_content: The vehicle used to transport children was observed to have a broken seatbelt on the second row and no air conditioning flowing from the vents on the very last row. The side window in the back row was also observed to be broke.

Correction Narrative: The administrator emailed photos indicating that the side window in the back row was no longer observed to be cracked. During inspection #4022409 the seatbelts were observed to have operating seatbelts on the second row and working air conditioning.


summary: 748.983(a) - First-aid-CPR renewal-Each caregiver must complete any new first-aid training, as required to maintain a current certification

raw_content: One of four staff member files reviewed was observed to have an expired CPR Certification: expired June 2024.

Correction Narrative: A training checklist has been created by the administrator containing the trainings required to fulfill minimum standards annually. The training checklist will be placed in each staff members folder by the administrator and a copy in a Master Folder titled Annual Training. The date of each staff members current training will be documented, along with the annual due date. These dates will also be documented and displayed on a Training Calendar in the main business office.  Administrator and Lead Supervisor will be responsible for checking each staff member's filed checklist on a monthly basis for staff members who will need to complete their trainings for the current month.  A memo will also be given to staff members who need to complete training for the month at least 2 weeks prior to their due date.


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

raw_content: The medication log for a child in care indicated that the child is being given one tablet at bedtime and not two as prescribed.

Category: Medication

Correction Narrative: when a child's medication is changed it will be placed in the folder by Assistant Director and checked for placement by the administrator and also explained to the Staff Member administering the medication when it is filled by assistant director.


summary: 748.930(b)(3) - Annual Training- Caregivers must have 1 hour normalcy training.

raw_content: One of four staff members was observed to have a delinquent annual normalcy training: last taken 01/18/23.


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

raw_content: 1 out of 4 files reviewed did not include the orientation or EBI notification.

Correction Narrative: LVES will have monthly folder checks to ensure all documents have been obtained, signed, and placed in the folder.  The folder checks will be conducted by LCCA and Assistant Director.


summary: 748.1693(c) - Nutrition-must ensure drinking water is always available to each child and served in a safe and sanitary manner

raw_content: During the walkthrough, water was not observed to be readily available.

Correction Narrative: During the walkthrough, water was observed to be readily available for children in care.


summary: 748.363(11) - Personnel records-For each person who transports a child, include copy of valid driver's license or DPS driver's license check done in last 12 months.

raw_content: One of four employee files reviewed was observed to have an expired driver's license as of 11/05/2023.

Correction Narrative: LVES has created a chart with document dates, and there will be a monthly folder and chart check to ensure that all transportation staff have current driver's licenses, and it is placed in the folder.  The folder and chart checks will be conducted by LCCA and Assistant Director.


summary: 748.4007(6) - Overnight Excursion-Each vehicle must have approved fire extinguisher, secured in passenger compartment & accessible to adults

raw_content: Vehicle used to transport children was not equipped with a fire extinguisher.


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 annual summary log was reviewed and is missing the component of how long the child was gone for or if the child did not return.

Correction Narrative: The annual summary log has been updated to include the duration of clock time hours the resident was absent from the property.


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

raw_content: The Recreational Activity Calendar does not depict planned daily indoor and outdoor recreational activities.

Correction Narrative: The recreation schedule has been updated and documents both daily planned indoor and outdoor activities.


summary: 748.1217(b)(11) - Admission Assessment-At admission, must include documentation of efforts to obtain required information, if any information is not obtainable

raw_content: 3 out of the 4 files reviewed did not contain an admission assessment.

Correction Narrative: Many residents are admitted during emergency situations lacking many documents. It will be mandatory that Admission Assessments will begin to be filled out at the point of the admission with any information the caseworker, investigator or transporter has on hand. During this time any information not obtained will be labeled "pending" and a reason given in written documentation for the absence of the information and notated on the checklist. The caseworker will be contacted every 7 days and efforts documented on the checklist.


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

raw_content: In 1 out of 4 files reviewed there was no TB exam conducted.

Category: Child Care

Correction Narrative: A checklist will be added to each resident's folder with a medical section indicating if there is a current TB Test present in the folder. The checklist will be dated and updated every 7th, 15th, and 30th day to ensure the resident has received the TB Test within 30 days of admission.


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

raw_content: 4 out of the 4 files reviewed did not obtain any record of any child being screened for vision or hearing.

Correction Narrative: The operation has filed vision and hearing exams for all children and have created  a checklist to ensure it is completed timely.


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: 5 of 5 children receiving emergency care services have been in care longer than 15 days without an extension.

Category: Emergency Care

Correction Narrative: A 7 Day Placement Extension Review Form will document the status of the child's placement stay needs. It will be completed on the 7th, 15th and 30th day of placement until the resident's discharge. Nearing the end of the 90th day of placement if DFPS request placement extension it will be submitted through the Provider's Portal and documented on the Placement Extension Form.


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

Deficiency Narrative: The unauthorized annual summary log was reviewed and is missing the component of how long the child was gone for or if the child did not return.


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

Category: Recreation Activities

Deficiency Narrative: The Recreational Activity Calendar does not depict planned daily indoor and outdoor recreational activities.


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

raw_content: The emergency evacuation & relocation diagram does not include a designated location inside of the operation to take shelter from threatening weather.

Correction Narrative: The emergency evacuation & relocation diagram do reflect a designated location inside of the operation to take shelter from threatening weather.


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

raw_content: 1 out of 4 child files observed was not accurate as the front of the file stated that the child had no food allergies however in the file placement summary it was indicated that the child was allergic to fish, shellfish, dust, insects, and moss.

Category: Organization and Administration

Correction Narrative: A checklist will be added to each resident's folder with a designated area indicating the Common Application has been checked for information on allergies, the Placement Summary has been checked for information on allergies, and a section designated for indicating the caseworker gave a verbal response to allergies.


summary: 748.1539(b) - Immunizations-The operation must maintain current immunizations records for each child in care, including any exemptions or exceptions

raw_content: It was found in 4 out 4 files reviewed that the facility did not attain the immunization records or place the documentation attempts in the child's file.

Correction Narrative: The correction the operation provided was that there is a new job aide check list that will be used to document pending and needed documents. This sheet will be updated and documented weekly until all documents have been obtained.


summary: 748.1437(1) - Discharge/Transfer Documentation-Must include date and circumstances of discharge or transfer

raw_content: In 1 out of 1 discharge file reviewed was observed to not contain any discharge documentation.

Correction Narrative: There is a Resident Discharge Form that is completed for each resident's discharge by attending staff and the DFPS Caseworker. It was not present the day of inspection but has now been completed.


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

raw_content: The operation's 2022 quarter 4 EBI numbers have not been reported.

Correction Narrative: The operation stated they will ensure to report quarterly EBI before the deadline and timely.


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

raw_content: The operation's annual fire inspection was not completed, with all items passing, by the due date.

Correction Narrative: Assessment Id: 	264171 - Pass Fire Inspection document was received and downloaded on Sharepoint.


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: There were no signed child rights forms in 3 of 4 files that were reviewed.

Correction Narrative: The corrections for the child files were sent via email with signed child rights.


facility_name: The Childrens Home of Lubbock ES and AC

summary: 748.2103(a) - Medication Storage & Destruction-Discontinued or expired meds & meds left at the operation must be inventoried & stored separately from current meds

raw_content: There were three expired over the counter medications stored with other medications currently being used.

Correction Narrative: Per email from Administrator, the expired medication was thrown out on 5/13/25. Overnight staff will go through the medicine cabinet once a week to ensure all medication kept is within their expiration date. All expired medication will be discarded properly.


summary: 748.1271(8) - Emergency Admission Documentation-Include the results of the suicide screening at admission, if required.

raw_content: One child record did not have a suicide screening. One child record had a suicide screening completed but was three days late. One child record had a suicide screening completed but with an undocumented date.

Correction Narrative: Per email from Administrator, the suicide ASK training template now has a place for date, child's name and staff's signature. The Case Manager will ensure that children 10 and older or children who have suicidal history will be screened at intake. Case Manager will ensure all screenings are readily available for licensing representatives in the child's file.  If required child's is not able to fill out risk assessment at time of intake, this will be noted in 72-hour report along with the reason to why child was not able to complete screen at time of intake.


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

raw_content: Medication logs reveiwed did not provide a reason the medication was prescribed.

Correction Narrative: Per email from Administrator, all current medication sheets that were missing " reason for medication" were filled out on 5/13/25 at the time of inspection. Unit Director talked with Case Managers reminding them to ensure the reason for medication is on all medication sheets during their daily medication checks. Moving forward, staff will receive a refresher training on proper documentation and how to properly fill out medication sheets to ensure all information is present according to licensing standards to ensure quality care and effective communication among caregivers.


summary: 748.930(b)(4) - Annual Training- Caregivers must have 2 hours transportation safety training if caring for children younger than 9 yrs old.

raw_content: One staff's traning record did not have an updated transportation training.

Correction Narrative: Per email from Administrator, the staff member whose training was not completed was not allowed to transport children until she completed transportation safety. All staff including overnight staff will have transportation safety if their job description specifies that they will be required to transport children. The staff member missing transportation training completed the transportation training on 5/23/25.