summary: 748.2553(1)(B) - EBI Release-Child released from short personal restraint within 1 minute, or sooner if danger is over or disruptive behavior is de-escalated

raw_content: A staff member conducted a personal restraint on a child in care for a minute and a half.

Correction Narrative:
On 04/15/2024 a corrective action plan was received from the operation stating the caregiver involved will undergo retraining on the proper procedures for releasing a child from short personal restraint. The training will emphasize the importance of prompt release within one minute, sooner, or after behavior has de-escalated, and supervise the caregiver to ensure compliance with the EBI skills moving forward. This will involve closer monitoring during his interactions with children and evaluations of their performance. Continuous improvement in care giving practices and feedback will be regularly obtained from children regarding staff members interaction, work ethics, and practices.

On 4/30/24 children were interviewed regarding restraints, when asked about the time length children stated that they are not held in restraints for a long time. They stated that the restraints last about a minute long. No concerns were found during the interviews, and children made no outcries of long-lasting restraints.


state: TX

facility_name: A New Day Foundation

summary: 748.2551(b)(3) - EBI Implementation-The caregiver must consider the potential risk of harm in using EBI versus the risk of not using EBI

raw_content: It was found during the investigation that a child was restrained near the stairs, which creates an increased risk of harm.  Additionally, the child was rubbing their head on the carpet as a means of self-harm, which posed less risk than the actual restraint.

Category: Individual Standards Evaluated

Standard Risk Level: High

Corrected at Inspection: No

Correction Narrative:
On 4/16/24 a corrective action plan was received from the operation: "The caregiver involved in the incident has been informed of the importance of considering the potential risk of harm when implementing his EBI skills. The caregiver involved in the incident now understands from scenarios and practical examples explained to him the risk of harm using EBI versus the risk of not using EBI. The caregiver will make an informed decision in the event EBI is utilized.
All caregivers will take into consideration harmful factors and the risk of using EBI versus the risk of not using EBI. The administrator, facility manager, and shift supervisors will ensure in the event EBI is utilized to take into consideration the potential risk of harm associated with using EBI versus not using EBI.
All Caregivers will be required to document the location within the faculty in the event EBI is required. This documentation will be reviewed by the administrator to ensure compliance and identify any areas for improvement."

On 4/30/24 children were interviewed regarding EBI at the facility and no concerns were found. No children made any outcries regarding EBI.


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

raw_content: It was found during the investigation that a child in care received significant bruising to their shoulder after a short personal restraint.

Correction Narrative:
On 4/16/24 a corrective action plan was received from the operation: "The caregiver involved in the incident has been informed to use a minimal amount of reasonable and necessary physical force whenever EBI is implemented. The administrator discussed with the caregiver involved in the incident the concept of minimal physical force and its application in caregiving scenarios. EBI Refresher Training will continue to be vital in ensuring that all staff members are up to date with the latest procedures, regulations, and best practices. Additionally, ongoing refresher training fosters a culture of continuous learning, improvement, professionalism, and accountability across the board within New Day Foundation. New Day Foundation's EBI training will include de-escalation techniques, the importance of applying minimal physical force, and scenarios to reinforce learning skills in effective intervention. New Day Foundation will implement these corrective actions and prevent similar incidents from occurring in the future. We recognize the importance of providing a safe and supportive environment for our children and are dedicated to upholding the highest standards of care and professionalism in our facility."

On 4/30/24, children were interviewed regarding EBI and were specifically ask about the amount of force when a restraint is done on them. When asked about the force being used, children stated that there isn't enough forced used to get hurt after the restraint. The children stated they have never received any bruising or injuries after being restrained. No children made any outcries about EBI during the interview. No concerns were found.


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

raw_content: The administrator reported becoming aware of the child's absence around 4pm of 05/19/23; the report was made to SWI at 1:24am on 05/20/23.

Standard Risk Level: Medium

Correction Narrative:
An inspection was completed today at the operation, and staff was interviewed regarding runaways and reporting. There were no concerns with the interview.

Written corrections received from the operation: I informed all our staff members as the administrator to call DFPS within the required 6 hours' time.


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

raw_content:
During a review conducted on March 31, 2023, it was determined that:
(1)	your operations administrator failed to ensure compliance with the current HM Plan(s); and
(2)	more than 12 months had elapsed since the effective date of the plan.
As you know, the heightened monitoring plans for your operation included a specific planned end date at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of post plan monitoring.  As a direct result of the administrators failure to ensure timely compliance with heightened monitoring plans, your operation was unable to successfully move to post-plan monitoring by the original planned end date necessitating previous extension.  Furthermore, due to your recent citation issued on September 22, 2022, your operations planned end date must now be revised again, and the period of heightened monitoring must be extended again.
Further details of the administrators failure to ensure compliance include the following:
Your operation received a high-weighted citation in a pattern/trend category on September 22, 2022.  Specifically, the operation was cited for 748.685(a)(5) Caregiver responsibility - being able to intervene when necessary to ensure child's safety. The operation met compliance on October 7, 2022.
-	Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring.
-	Operation was unable to meet compliance with Medium-High or High weighted licensing citations.
Finding: 748.535(2)  The licensed administrator must ensure the operation complies with current heightened monitoring plans.

Standard Risk Level: Medium High

Correction Narrative: An HM extension was approved effective 3/31/2023.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your CPA/GRO in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 748.535(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is 10/1/2023.


raw_content:
During a review conducted on September 30, 2022, it was determined that:

(1) your operations administrator failed to ensure  compliance with the current HM Plan(s); and

(2) 12 months had elapsed since the effective date of the plan.

As you know, the heightened monitoring plans for your
operation included a specific "planned end date at the
12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of post plan monitoring. As a direct result of the administrators failure to ensure timely compliance with heightened monitoring plans, your operation is now unable to successfully move to post-plan monitoring.

Further details of the administrators failure to ensure compliance include the following:

Your operation received a High-weighted citation in a pattern/trend category on September 22, 2022.  Specifically, the operation was cited for 748.685(a)(5) Caregiver responsibility - being able to intervene when necessary to ensure child's safety.  The operation has not met compliance.

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

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

Correction Narrative: An HM extension was approved effective 9/30/2022.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your CPA/GRO in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 748.535(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is 3/30/2023.


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

Category: Medication

Correction Narrative:
Several medication records did not align with the medication count.

Medication records were reviewed. There were no concerns.


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

raw_content: Staff was not able to intervene fast enough due to the fact she was driving when the altercation started and the children in care where able to punch one another in the face.

Correction Narrative: New Day Foundation's administrator identified the staff who was driving when two boys punch one another in the face. Staff will henceforth intervene and immediately pull off the road /street   in the event kids are involve in a verbal or physical fight. Staff will further ensure children are counsel prior to riding the van, request for assistance and keep the children safe.


summary: 748.1217(a) - Admission Assessment-Must provide initial evaluation of appropriate placement & ensure that necessary information for service planning is obtained

raw_content: It was observed in the child's file reviewed, that the admission assessment was completed a day after the child was placed at operation.

Correction Narrative: Leadership emailed Corrective Action Plan that took place on 7/15/2022.


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: Upon viewing child's file, there was no documentation of TB test for child.

Correction Narrative: Leadership sent a picture via email of the TB test results.


summary: 748.1223(a) - Admission-Medical exam by health-care professional within 30 days after admission, unless documentation of medical exam within past year available

raw_content: One child file reviewed was found that the medical annual check up was due in May 2022 however it was completed today July 11, 2022.

Corrected at Inspection: Yes


summary: 748.453(c) - Unauthorized Absence - Annual summary logs should be available to Licensing for review and reproduction, upon request.

raw_content: The operation did not have an annual summary log to review.

Correction Narrative: An email from the administrator was received with an attachment of the annual summary logs the staff have been instructed to utilize moving forward.


summary: 748.303(a)(9)(A) - Serious Incident-Report to CCL within 2 hours of notifying LE the absence of a child developmentally/chronologically 6 to 12 years old.

raw_content: The operation did not report to licensing when a child ran away for three hours.

Correction Narrative: An email from the administrator was received stating the following: New Day Foundation staff members will henceforth call DFPS phone number (1-800-252-5400) and report to licensing in the event of an elopement of a child in care.


summary: 748.4653(a)(2) - Pre-Service Training- All caregivers must receive 16 hours of EBI training, if operation prohibits EBI then 8 hours only.

raw_content: Upon viewing staff file, 4 hours of EBI was missing.

Correction Narrative: Picture of EBI certificate was emailed to inspector.


summary: 748.393(b)(4) - Active child record - Ensure record is locked and kept in a safe location or locations

raw_content: The medication log was observed on a shelf in the common area.

Category: Reports and Record Keeping


summary: 748.1205(a)(2) - Admission Documentation-Includes court orders establishing who is the managing conservator for the child, if applicable

raw_content: Two of four child files reviewed does not contain the managing conservator's contact information.

Category: Admission, Service Planning, Discharge

Standard Risk Level: Medium Low

Correction Narrative:
An email from the administrator was received stating the following: The identified records have been updated to include the DFPS Caseworker's contact information.

A New Day Foundation Inc. will complete a quality records review to ensure all Conservator contact information (phone number) are included in all child records.


summary: 748.941(a)(3) - Training Criteria- Must include an evaluation tool to determine whether the person obtained the information necessary to meet the stated objectives

raw_content: Three of three staff files reviewed did not contain an evaluation or assessment tool.

Category: Training and Professional Development

Correction Narrative: An email from the administrator was received stating the following: A New Day Foundation Inc. will complete the required evaluation and assessment for all personnel. A New Day Foundation Inc. will develop an evaluation and training schedule to ensure all personnel are on the same training and evaluation schedule agency wide.


summary: 748.1209(a) - Child Orientation-Provided to child who is 5 years old or older within 7 days of admission and geared to child's intellectual level

raw_content: Two of four child files reviewed did not include the required orientation documentation such as policies on mail or gifts.

Correction Narrative: An email was received from the administrator stating the following: A New Day Foundation Inc. will revise its admission documentation to reflect the identified policies regarding mail and personal gifts.


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 fire inspection has not been completed within the required timeframe.

Correction Narrative: An email from the administrator was received with an attachment of the Harris County Fire Marshal proof of inspection.


summary: 748.311(2) - Serious Incident Documentation-Includes time and date of incident

raw_content: Several serious incident reports reviewed in two children's files did not include the date or start time the incidents occurred. The serious incident report documentation doesn't include the operation's contact information. The incident reports do not include surrounding circumstances of the incident that occurred.

Correction Narrative:
An email from the administrator was received stating the following: The serious incident form was revised to include the identified missing information.

All Direct Care Staff and Administrative Personnel are notified of the revision and the new form placed in residential unit for use.


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

raw_content: Two of two discharged children's file reviewed does not contain the required discharge documentation such as the discussion with the child about being discharged or the medication the child was prescribed.

Correction Narrative: An email from the administrator was received stating the following: A New Day Foundation Inc. will revise its discharge protocol to include a formal therapeutic documented case note identifying the discharge discussion between the child and the assigned Case Manager or designee.


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

raw_content: A caregiver at the operation has engaged in inappropriate behavior by  pinching, punching, and pushing children in care. The same caregiver has intervened in behavioral intervention when it was not necessary as the situation was already being handled by another caregiver.

Correction Narrative:
The first action plan submitted by the agency did not provide details as to how the identified concern had been addressed. On 5/31/22 a revised action plan was submitted and detailed what action had been taken. The details are listed below.
(a)The administrator met 1:1 with identified employee and re-enforced standard and high expectation that is required .
(b) he identified employee will be monitored and supervised by the supervisor.
(c) The administrator will inquire / get
feedback from the children in care and
employees regarding the identified
employee intervention and work ethics.
(d) Caregiver will apply his therapeutic training and conduct himself in a professional manner
henceforth in the workplace
6/13/2022- Follow-up inspection conducted during HM visit. Children were interviewed concerning discipline. No concerns were found.


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

Correction Narrative:
The following email was provided by the administrator:

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.

Specifics It's confirmed that a physical restraint took place; the operation was unable to produce the necessary documentation following the intervention.

Corrective Actions Planned and/or Taken:
New Day Foundation immediately conducted a general staff meeting regarding DFPS standard 748.2855(a)

New Day Foundation's staff members will henceforth document the EBI when perform and inform the administrator after each intervention

The administrator will review all EBI documents and meet with the child after the intervention / the next business day.

The Case Manger will ensure and has been designated to placed / file all EBI documents in a child's record.

New Day Foundation's case manager will give / make available all EBI documents to DFPS workers upon request

Target Implementation/Completion Date:
Implementation effective immediately as of February 3rd, 2022 and ongoing. staff meetings and   Inservice training focusing on the importance of documentation and record keeping will continue indefinitely.

Responsible For Implementation:
       1.The administrator and the Case Manger will ensure EBI documents are review and place in the child's record. New Day Foundation's philosophy, program model, therapeutic interventions will be implemented in the delivery of services. All services and interventions will be documented and place in the child's record.

Thanks
Isaac Karnley/Administrator


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

raw_content: Three of thirteen children medication inventory proved to be inaccurate. The pill count did not match the documented pills remaining.

Correction Narrative: During follow up inspection, eleven medication records were reviewed and contained accurate information.


summary: 748.1103(b)(1) - Informing child of rights-Child rights must be written in simple, non-technical terms

raw_content: One of four child files did not contain a child rights document.

Category: Children's Rights

Correction Narrative: During follow up inspection, two files reviewed contained the children's rights document.


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

raw_content: One child medication log recorded the incorrect dosage compared to the actual prescription. The employee list has the incorrect name of an employee compared to the background check system and employee file.

Correction Narrative: During follow up inspection, all records reviewed contained accurate information. Including signature of the person performing internal review.


summary: 748.1339(b) - Initial Service Plan-For treatment services, service planning team must include two professionals

raw_content: The child's Intial Service Plan did not have all signatures required.

Standard Risk Level: Low

Correction Narrative: Case manager emailed the initial service plan with required professional signatures.


summary: 748.505(b)(3) - Minimum qualifications for employees-Physically, mentally, emotionally capable of performing assigned tasks; has the necessary skills

raw_content: An employee of the operation has demonstrated an unstable mental capacity by making concerning comments to others.

Correction Narrative: Employee's employment was terminated on 12/10/21.


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: Operation was out of ratio at art time transitioning into lunch. it was one staff with 6 children. The operation devided the children to meet ratio requirements.


summary: 748.125(b) - All employees and caregivers must be aware of and follow your operation's policies and procedures

raw_content: I reviewed one staff file and the job discription was not signed and dated.

Correction Narrative: Written corrections were received on 7/10/21. The Administrator identified the employee who job description was not signed. The employee immediately signed the job description and was placed in employee personnel file. The  administrator will monitor all  employee folders and ensure all employees job descriptions  are signed as required .


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

raw_content:
The medication in a child's medication log was not properly documented.

Ms. Fields corrected the med log during the inspection.


raw_content: One medication log was found to be signed and dated for the following day.

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

Correction Narrative:
Administrator submitted written corrections.
The treatment team director will ensure two professional signatures are acquired whenever a service plan is completed.


raw_content: It was observed that one caregiver was supervising 8 children for at least 10 minutes. Staff returned to their assigned area, operation was back in ratio.

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


raw_content: One child's file reviewed only had one licensed professional signature.

Standard Number / Description: 748.1339(b) - Initial Service Plan-For treatment services, service planning team must include two professionals

Correction Narrative: New Day Foundation as of 06/07/2021 immediately corrected the deficiency by acquiring the signature of another professional. The treatment team director will ensure two professional signatures are acquire whenever a service plan is completed. The signature portion of the service plan has been signed as required


facility_name: Blue Skies

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

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

Correction Narrative: A follow up inspection was conducted and staff interviewed confirmed that administration / supervisors regularly discuss discipline and children rights.  Staff stated that they are having monthly meetings/trainings and reminders from administration. SAMA trainings and refreshers regularly, and sign in sheets were provided and training logs provided.  Staff member was also immediately terminated from operation who viiolated this standard rule.


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

raw_content: A staff member admitted during the investigation that they hit a child in care at the operation.  Video footage shows that staff member did in fact hit and punch children in care at the operation.

Correction Narrative: A follow up inspection was conducted and staff interviewed stated/confirmed they were properly trained in SAMA/TBRI, and stated that no physical discipline occurs at the operation.  Children interviewed at the operation denied any physical disipline/corporal punishment at the operation, and stated they are treated well at the operation.  The staff member who violated this standard rule was immediately terminated from the operation.


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: A child in care was missing a vision and hearing test upon admission.

Category: Child Care

Correction Narrative: Email received stating moving forward to correct issue with vision and hearing requirements/screenings will either be checked in the three-day visit or by the nurse within the prescribed time frame set by minimum standards.


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

raw_content: A child in care did not have a dental appointment with 90 days of admission.

Correction Narrative: Email received stated when children arrive at operation, they have established a secondary dental provider to help meet timeframes that are required by minimum standard requirements.  At the time of the appointment the dental availability was outside of the 90-day requirements of minimum standards.


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: Due to pattern of repeated deficiencies cited during both inspections and investigations operation has not implemented effective or sustained corrective action to address areas of concern.

Correction Narrative: A follow up inspection was conducted, and staff interviewed confirmed that Administration/Administrator supervises and directs supervisors and staff toward policies and procedures. Along with providing trainings such as SAMA,EBI, and discusses proper practices toward supervision of the children in care at the operation.


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

Deficiency Narrative: This standard was found deficient as part of a DFPS Investigation.

Correction Narrative: A follow up inspection was conducted and staff interviewed confirmed that management/supervisors regularly discuss discipline and children rights.  Staff also is provided with regular SAMA training and refreshers on a routine basis at the operation.  Sign in sheets were provided as well/ logs of refresh trainings.  Staff member was also immediately terminated from operation who violated this standard rule.


raw_content: A staff member did not use prudent judgement when they gave children in care access to a vape pen, edibles, and inappropriate photographs.

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:
A follow up inspection was conducted, and staff interviewed confirmed that management and supervisors regularly discuss discipline.  Staff also is provided with regular SAMA training and refreshers on a routine basis at the operation.
Information logs on refresher trainings were provided.


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

Correction Narrative: A follow up inspection was conducted, and staff interviewed confirmed that management/supervisors regularly discuss discipline and children rights.  Staff also is provided with regular SAMA training and refreshers on a routine basis at the operation.  Sign in sheets were provided as well/ logs of refresh trainings.  Staff member was also immediately terminated from operation who violated this standard rule.


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: Staff interviewed during the investigation confirmed that she conducted the restraint on the child in care before using any other de-escalate technique.

Correction Narrative: A follow up inspection was conducted and staff interviewed confirmed that management/supervisors regularly discuss discipline and EBI or SAMA trainings.  Staff also is provided with regular SAMA training and refreshers on a routine basis at the operation. SAMA training for new hires at operation was currently taking place.  Logs for training refresher coursed provided.


summary: 748.2605(a)(5) - Personal Restraints Prohibited-Restraints that twist or place the child's limb(s) behind the child's back

raw_content: A staff member placed a child in care's arm behind their back during a restraint.

Correction Narrative: A follow up inspection was conducted and staff interviews confirmed that management/supervisors regularly discuss discipline and EBI or SAMA trainings.  Staff also is provided with regular SAMA training and refreshers on a routine basis at the operation.  SAMA training for new hires at operation was currently taking place.  Staff member was terminated at operation who commited improper restraint.


summary: 748.126(b) - All employees and caregivers must be aware of and follow your policies and procedures

raw_content: Staff admitted to using a prone restraint which is against the operations EBI policies.

Correction Narrative: A follow up inspection was conducted and staff that were interviewed confirmed management regularly discusses policies and procedures at the operation.  Information is provided at any time at the operation via conversation with supervisors, trainings and online access for policies at operation, corporate policies, an child rights.


summary: 748.2003(b)(6) - Administration of prescription medication-ensure a person trained in & authorized to administer prescription medication administers the medication

Correction Narrative: Administrator emailed compliance plan to RCCR inspector on 5/12/2025. The operation has implemented a Nurse Delegation agreement form to show medication training has been provided and the staff is approved to administer prescription medication.


summary: 748.1209(d) - Child Orientation-document in child's record when orientation occurred, any required information omitted, reason for any omissions

raw_content: Child orientation was not in two child files. Operation stated topics are discussed when admitting the children, but it has not been document.

Correction Narrative: Email received stated For all current residents an orientation was completed with new sign-in sheets, with resident signatures.


summary: 748.2151(f) - Medication record-must include identification or prohibited prescription medication, non-prescription medication, or supplements for the child

raw_content: Two child medication records had a space for prohibited prescription or allergies to medication however this was left blank.

Correction Narrative: Email received stated Med Log records were completed leaving no blank spaces on the records, i.e. any medication allergies.


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

raw_content: When reviewing two child's records the known contraindications to the use of restraint was not addressed.

Correction Narrative: Email received stating in all child records an addendum was created to specifically list any known contraindications to the use of restraint. Moving forward, this will be included in both the Preliminary Service Plan, the Initial Service Plan, and the Admissions Assessment.


summary: 748.2151(c)(7) - Medication record - must include the child's refusal to accept medication

raw_content: A child refused to take medication, this refusal or the reason of refusal was not documented on the medication record.

Correction Narrative: Email received stated when children refuse medications, not only will there be documented as a serious incident report in the child's record, the refusal will also be indication on the med log sheet for each refusal. This deficiency was corrected on 12/5/2024.


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

raw_content: While reviewing medication logs the reason why the medication is being prescribed was not listed for two child files.

Correction Narrative: Email received stated med Log records were completed leaving no blank spaces on the records, i.e. the reasons for the medications.


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

raw_content: While reviewing background checks there were three employees who are not long employed since mid-November, with active background checks.

Correction Narrative: Email received stated upon termination of employment, Human Resources will inactivate the employees in the DFPS Provider Portal, within three (3) business days. On this specific deficiency, this was remedied on 12/4/2024.


Deficiency Narrative: This standard was found deficient as part of a DFPS Investigation

Correction Narrative: Staff interviewed confirmed management regularly discuss discipline and child's rights. Staff were also provided SAMA refresher. Sign in sheets were provided.


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

raw_content: Video reviewed and staff interviews confirm that staff engaged in a physical altercation with a child in care.

Correction Narrative: Staff interviewed confirmed management regularly discuss discipline. Staff were also provided SAMA refresher. Sign in sheets were provided.


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

raw_content: Video reviewed showed staff pouring a cup of ice on child's head.


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

raw_content: Interviews reported hearing the staff curse at a child in care.


raw_content: An employee engaged in a power struggle with a child in care while matching their energy and escalating the situation further.

Correction Narrative: Administrator emailed compliance plan to RCCR inspector on 6/27/24. Prior to this investigation the staff in question was coached on engaging in power struggles with residents. The staff will receive training on Stress Management and Preventing Burnout. They will be required to check in with supervisors every shift and will tap out when they, themselves are escalated. Document was uploaded to document library.


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: A child's service plan does not include personal or specific strategies to meet the child's behavioral, supervision, and high-risk needs.

Correction Narrative: RCCR Supervisor interviewed Administrator at Blue Skies on 5-14-2024, inspection #4001808. They stated they are working on service plans and making them more detailed and to fit the child's needs. They met with the new case manager to go over what changes need to be made.


summary: 748.1339(b) - Initial Service Plan-For treatment services, service planning team must include two professionals

raw_content: A child's service plan did not have the required amount of team members/professionals present.


summary: 748.2307(3) - Other Prohibited Punishments-threatening with the loss of placement as discipline or punishment

raw_content: A staff member was observed on video telling a child that "we need to get you out of here."

Correction Narrative: RCCR Supervisor completed a follow up inspection #4001808, on 5-14-2024. 2 children were interviewed along with 1 staff member about EBI and discipline. The children stated that staff hasn't been restraining the children as much. They stated they only get restrained if they are trying to hurt themselves or someone else. The staff member stated they have been retrained and get refreshers often. They feel it has been helping and have seen a decrease in restraints. The administrator was interviewed and stated the EBI numbers have decrease significantly since they have retrained staff. Regarding the staff in the allegations, they were written up for the comments. They stated they have seen a difference in the behavior of the staff, and they have no issues since.


summary: 748.2307(15) - Other Prohibited Punishments-using or threatening to use emergency behavior intervention as discipline or punishment

raw_content: A staff member was observed on video saying they will restrain a child and make them feel the ground.


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

raw_content: A staff member hit a child in the face as a means to get the child to comply.

Correction Narrative: The staff were interviewed and they stated they were retrained for EBI and are doing training this week with de-escalation. They have seen a big decrease in restraints.


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

raw_content: Children confirmed during interviews that they observed the staff restrain the child.


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

raw_content: During the interviews staff confirmed statements were made indicating the child needed to comply and learn to behave as they continued with a restraint.

Correction Narrative: The staff were interviewed and they stated they were retrained for EBI and are doing training this week with de-escalation. They have seen a big decrease in restraints. .


summary: 748.2605(a)(1) - Personal Restraints Prohibited-Restraints that impair child's breathing by putting pressure on child's torso

raw_content: Staff did not release the child from the restraint after the child said they could not breathe. Collateral staff confirmed during interviews that the staff member was directed to release the child from the restraint and the child said they could not breathe.


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 child in care was hit in the face by operation staff.

Correction Narrative: The staff member was fired.


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

raw_content: A restraint was implemented after the child was walking away from the situation. The child was not a danger to themselves or others at the time.


raw_content: Video showed staff did not attempt a less restrictive intervention prior to initiating a containment on a child in care.

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

Correction Narrative: Interviewed 2 staff member and they talked about being retrained in EBI last week. The staff EBI training certificate were reviewed.


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

raw_content: Interviews confirmed staff did not keep the children in line of sight while the children played in the fort.

Correction Narrative: Case manager reported all staff are informed of the supervision. A follow up inspection was conducted, and case manager reported all staff are informed of the supervision. Staff interviewed stated their lead supervisor goes over supervision during shift change if it has changed for the child or they have a new child.


summary: 748.2605(a)(5) - Personal Restraints Prohibited-Restraints that twist or place the child's limb(s) behind the child's back

raw_content: A staff member placed a child's arm behind their back during a restraint.

Correction Narrative: After reviewing this event, Blue Skies immediately notified DFPS Hotline as this event was not permitted in Blue Skies Procedure. The staff performed a restraint that was not trained on nor permitted by Blue Skies procedure. The staff member was terminated, and retraining took place for all other staff, beginning on April 12th.


raw_content: Staff interviewed during the investigation confirmed the situation was not an emergency that would warrant a restraint.

Correction Narrative: After reviewing this event, Blue Skies immediately notified DFPS Hotline as this event was not permitted in Blue Skies Procedure. The staff in question was immediately placed in administrative leave and was terminated. All of Blue Skies staff were retrained in EBI and Blue Skies EBI procedures.


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

Correction Narrative: Staff were retrained on EBI procedures and policies. The action taken by this particular staff was not condoned nor tolerated by Blue Skies. He was placed on administrative leave and then terminated before the conclusion of this investigation.


raw_content: A staff member engaged in a power struggle with a child and pushed the child to the ground.

Standard Number / Description: 748.2463(3) - Emergency Behavior Intervention-Never used as a means to get a child to comply

Correction Narrative:
Inspection was completed on 5-3-2024 at Blue Skies. Staff were interviewed and they stated they have been retrained in EBI and will be getting a refresher for the next couple of weeks. They staff stated they have seen a decrease in restrains the past month and most of the staff are working on their communication. EBI training for the staff was reviewed and the sign in sheet. SA.
Email received 4/30/24 After review of this incident, leadership put all staff back through EBI trainings, including the use of the verbal de-escalation processes. Supervisors were retrained on responding to crisis interventions and best practices.


raw_content: A child's service plan does not include personal or specific strategies to meet the child's behavioral and supervision needs. It also does not include signatures.

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

Correction Narrative:
Inspection was completed on 5-3-2024. The case coordinator was interviewed and stated she is working on updating all the service plans to include more details. She pulled up a service plan that she has completed that showed more detail in the level of supervision. We also talked about getting signatures for all the service plans which she had on the update service plan. SA
Email received 04/30/24 Training and feedback has been provided to the Case Coordinator, whom has already made corrections to Service Plans moving forward. These corrections are noted as having more thorough descriptions of supervision and de-escalation techniques that are individualized and specific. After review of this incident, leadership put all staff back through EBI trainings, including the use of the verbal de-escalation processes. Supervisors were retrained on responding to crisis interventions and best practices.


summary: 748.125(d)(4)(E) - Suicide Screening- Must be administered immediately if the child exhibits warning signs that necessitate a suicide screening be conducted.

raw_content: A suicide assessment was not administered after a child in care self-harmed.

Correction Narrative: Administrator emailed safety plan and suicide risk assessment to inspector on 12/13/23. A suicide screener was given to child in care on 12/12/23. The child refused to answer the questions. Their refusal is documented. The safety plan states staff will remove potentially dangerous items from room and the child will be in line of sight with wellness checks every 5 minutes.


summary: HRC42.046(1) - Public Notice and Hearing Requirements

raw_content: The notice must be published at least 10 days before the date of the public hearing. The notice was not published until 7/30/23 for hearing to be held on 8/2/23.

Correction Narrative: Inspector spoke with Ryan Lynn about notifications being sent out in a timely manner. Ryan stated he understood and will comply with minimum standards.


summary: 748.191(3) - Required Postings-Post emergency and evacuation relocation plans in each building and living quarters used by children where all may view them

raw_content: During the first application walk through there was no emergency evacuation plan posted in the building.

Category: Organization and Administration

Correction Narrative: During the follow-up inspection the required emergency and evacuation postings were posted as required. Pictures were taken.


summary: 748.3271 - First Aid Kits-All separate living areas & buildings must have first-aid kit available; first-aid kit must be available for field trips

raw_content: There were no first aid kits in the operation.

Category: Safety and Emergency Practices

Correction Narrative: At follow up inspection it was verified that the operation had the required first aid kits. Photos were taken.


summary: 748.3001(a)(1) - Sanitation Inspection-Sanitation official must conduct a sanitation inspection before initial permit issued

raw_content: A health inspection was not completed.

Deficiency Narrative: A health inspection was not completed.

Correction Narrative: At follow up inspection it was verified that the health inspection had been completed 7/26/23.


facility_name: New Hope Youth Center

summary: 748.3421(2) - Poisons-The operation must ensure that poisonous or flammable materials are kept separate from medication, food, food prep and dining surfaces

Correction Narrative:
A can of Lysol was on the kitchen counter next to several bags of chips and next to the stove where food was being cooked.

A full walkthrough was completed at the operation, and no chemicals were observed.


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

raw_content: The child's managing conservator stated he was not informed about the incident and found out about it when the child mentioned it to him. The PM, who is in charge of calling CPS stated he believed he had contacted the CPS worker but was not one hundred percent certain. The administrator stated the PM is the person who calls CPS as is required, but that unfortunately they don't have phone records of it occurring. Per the operation's policies and procedures, the facility will notify the caseworker as soon as possible but no later than 2 hours.

Correction Narrative: RCCR Supervisor received an email from Administrator Mitchell with the compliance plan. It states residents will be taken to the doctor as soon as any medical concerns are reported. In the event an incident occurs after business hours they will be taken to the Urgent Care or Emergency Room. Caseworker/managing conservator will be notified by Administration or Residential Manager when an incident occurs with a resident as soon as possible but no later than 24 hours.


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

raw_content: During the walkthrough of the facility, one Hot Shot ant, roach and spider killer and one insect repellant net weight 8.125 oz were observed on top of the fridge in the kitchen while children are at the facility due to spring break.


summary: 748.393(b)(3) - Active child record - Ensure record is kept accurate and current

raw_content: During the review of one childs file, different date of birth was noticed in the children list and another date of birth in the childs admission assessment Part 1. This was corrected at inspection.


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

raw_content:
During a review conducted on October 14, 2024, it was determined that:

(1) your operations administrator failed to ensure compliance with the current HM Plan(s); and

(2) 12 months had elapsed since the effective date of the plan.

As you know, the heightened monitoring plans for your operation included a specific planned end date at the 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to
move out of active heightened monitoring to a phase of post plan monitoring. As a direct result of the administrators failure to ensure timely compliance with heightened monitoring plans, your operation is now unable to successfully move to post-plan monitoring.

Furthermore, your operations planned end date must now be revised, and the period of heightened monitoring must be extended again.

Further details of the failure of your operations administrator to ensure compliance include the following:

- Operation was unable to meet compliance with Medium-High or High weighted licensing citations, including having an open investigation(s).

Finding: 748.535(2)  The licensed administrator must ensure the operation complies with current heightened monitoring plans.

Correction Narrative: An HM extension was approved effective 10/14/2024.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your GRO in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 748.535(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is 4/15/2025.


raw_content:
During a review conducted on April 12, 2024, it was determined that:
(1)	your operations administrator failed to ensure compliance with the current HM Plan(s); and
(2)	more than 12 months had elapsed since the effective date of the plan.
As you know, the heightened monitoring plans for your operation included a specific planned end date at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of post plan monitoring.  As a direct result of the administrators failure to ensure timely compliance with heightened monitoring plans, your operation was unable to successfully move to post-plan monitoring by the original planned end date necessitating previous extension. Furthermore, due to your recent citation issued on September 26, 2023, your operations planned end date must now be revised again, and the period of heightened monitoring must be extended again.
Further details of the administrators failure to ensure compliance include the following:
Your operation received a high weighted citation in a pattern/trend category on December 4, 2023.  Specifically, the operation was cited for 748.2307(6) Other Prohibited Punishments-pinching, pulling hair, biting, or shaking a child. The operation met compliance on December 11, 2023.
- Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring.
- Operation was unable to meet compliance with Medium-High or High weighted licensing citations
Finding: 748.535(2)  The licensed administrator must ensure the operation complies with current heightened monitoring plans.


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

raw_content: Several children in care stated that they have been threatened by staff at the facility.

Correction Narrative:
Email received from Administrator Mitchell stating that Staff Meeting/Training scheduled for 4/24/24.  Administration will review with staff the Minimum Standard that was cited, review and provide a copy of the NHYC Child's Rights/TDFPS Child's Rights, as well as provide training to educate them on methods that are more effective in dealing with a child.

Email sent on 04.25.2024 with sign in sheet for training provided on 04.24.2024


summary: 748.3441(a) - Food Preparation-Food & drinks must be of safe quality, stored, prepared, distributed, & served under sanitary & safe conditions

raw_content: During the walkthrough of the facility several rotten pears were observed inside the fruit bowl in the kitchen counter. All rotten fruits were trashed by staff in my presence.


summary: 748.3421(1) - Poisons-The operation must ensure that poisonous or flammable materials are stored in their original, labeled containers

raw_content: During the walkthrough of the facility, one Green gallon of all purpose pinalen Fresh pine cleaner was observed  on top of counter next to the washing machine.


raw_content:
During a review conducted on October 11, 2023, it was determined that:

(1) your operations administrator failed to ensure compliance with the current HM Plan(s); and

(2) 12 months had elapsed since the effective date of the plan.

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

Your operation received a medium-low weighted citation in a pattern/trend category on September 26, 2023.  Specifically, the operation was cited for 748.1335 Initial Service Plan-Complete the initial service plan within 45 days after admission. The operation met compliance on September 26, 2023.

- Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring.

Correction Narrative: An HM extension was approved.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your CPA/GRO in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 748.535(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is 4/12/24.


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

raw_content: One child service plan was reviewed today. It was observed during the review of the plan that the child was admitted on 08-10-23 but initial service plan was completed on 9-25-23 which is 46 days. Agency staff stated that the initial servce plan was completed on 09-22-23 and not 9-25-23 as indicated in the plan but was not able to provide me with any evidence that the meeting was held on 9-22-23.

Correction Narrative: Written correction was sent via email today 9-26-23. In the correction, the operation stated that henceforth, they will be completing initial service plans within 45 days from date of child admission.


summary: 748.2307(6) - Other Prohibited Punishments-pinching, pulling hair, biting, or shaking a child

raw_content: It was determined that staff was pinching a child's nose to get the child get off of him.

Correction Narrative: Follow up by inspection was completed. 2 staff were interviewed, and they confirmed a refresher course for EBI was held for all staff. The operation also sent a written correction, in its correction, it stated that a refresher course was held on EBI.  Copy of the refresher training certificate for 10-8-23 by a professional licensed trainer and photo was taken after approval.


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

raw_content: It was determined that child was left outside unsupervised for about 10 to 15 minutes while staff was inside the facility.

Correction Narrative: 2 staff were interviewed, and they confirmed that a refresher course for Supervision was held to reiterate the importance of ensuring that staff on duty should be able to be accountable for resident's actions at all times. They stated that staff should be able to see what residents are doing at all times.


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

raw_content: It was determined that a child grabbed a pair of scissors that were unattended from the kitchen counter and threatened to stab staff.

Correction Narrative: 2 staff were interviewed, and they confirmed that a meeting was held with administrator and that staff will ensure that all scissors are removed immediately residents finished using it as well as all other items that could be deemed unsafe.  The also confirmed that Administration/ Managers / Houseparent are doing walk through each shift to ensure that no unsafe items are left unattended. They also stated that Minimum Standard was reviewed with staff.


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: It was observed during the walkthrough of the facility that the Air Conditioner in the Day room is leaking water from the unit to the ground. It appears the leak has been going on for some days which has resulted to some part of the wall appeared to be soaked from the leaking water from the A/C Unit.


raw_content: It was observed during the review of a childs file that the admission assessment form Part 1 has wrong date of admission for the child. Child correct date of admission was 6-16-23 but the date of admission in the admission assessment form Part 1 has 3-8-21. The Administrator corrected the information to reflect the correct date of admission which was 6-16-23.

Standard Number / Description: 748.393(b)(3) - Active child record - Ensure record is kept accurate and current


raw_content: During the review of a childs initial service plan, it was observed that the DOB for the child in the initial Service plan is different from the correct DOB which is in the childs DFPS placement authorization.


summary: 748.303(a)(12)(A) - Serious Incident-Report to Licensing as soon as aware of a suicide attempt by a child

raw_content: The administrator confirmed that the incident went on for several hours. Licensing was not made aware of the incident until the following day.

Correction Narrative: Follow up to assessment #269388. 2 serious incident reports were reviewed for 5-21-23 and 5-22-23, and no concern was observed. Also spoke with administrator regarding ensuring that staff reports SIR timely to the hotline.


raw_content:
During a review conducted on April 10, 2023, it was determined that:

(1) your operations administrator failed to ensure compliance with the current HM Plan(s); and

(2) 12 months had elapsed since the effective date of the plan.

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

Your operation received a medium-low weighted citation in a pattern/trend category on February 15, 2023.  Specifically, the operation was cited for 748.2857(b) A copy of EBI documentation provided to the parent must be maintained in the childs record. The operation met compliance on February 16, 2023.

- Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring.

-Operation was unable to meet compliance with Medium-High or High weighted licensing citations.

Correction Narrative: An HM extension was approved effective 4/10/2023.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your CPA/GRO in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 748.535(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is 10/11/2023.


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

raw_content: Three out of five children interviewed stated a staff member calls them names.

Correction Narrative:
Written corrections were received by the operation. The operation stated that the staff that was involved in the standard violation was counseled by the Administrator as well as trained on the specific minimum standard that was violated. He received Sensitivity training on 4-27-23. Follow up inspection will be complete.
An in person follow-up inspection was conducted on 05/10/2023 and there were no concerns.


summary: 748.2857(b) - A copy of the documentation provided to the parent must be maintained in the childs record.

raw_content: Four out of four EBI documentation reviewed did not document that the youth's parent was notified.

Category: Emergency Behavior Intervention

Correction Narrative: A copy of updated EBI form was emailed to show where   parent will be notified of EBI.


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

raw_content: One out of four child records reviewed did not include an immunization record or documented attempts to obtain the record.


summary: 748.1007(c)(1) - Child/caregiver ratio-Asleep caregiver may care for 10 children if any child in group requires treatment services

raw_content: 3 children stated that staff are sleeping while on shift. The operation currently has 11 children in care with one staff during overnight shift.

Correction Narrative:
Leadership emailed over corrective action on 1/31/2023 and stated that Administration will meet with each individual overnight staff to stress the importance and safety of them remaining awake and monitoring the residents during their shift. As well as Administration will review the Minimum standard with them that is affected. All discussions will happen by 2/3/2023.

on 2/3/2023, leadership sent correction via email. All staff received supervision training and certificates were received. Leadership had a meeting with overnight staff to discuss the no sleeping policy and the signature page was sent via email.


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

Correction Narrative: The victim child and the Caregiver supervising the group stated the Caregiver had stepped away to help another resident when a physical altercation happened. No concerns regarding general supervision were reported.


summary: 748.2605(a)(5) - Personal Restraints Prohibited-Restraints that twist or place the child's limb(s) behind the child's back

raw_content: Both the victim child and the Caregiver who performed a restraint, stated the child's arms was placed behind his back.

Correction Narrative: Follow-up was conducted by inspection. Children were interviewed and there were no concerns. Written corrections was sent to inspector via email that they will schedule restraint training and discipline with updated curriculum.


raw_content:
During a review conducted on October 7, 2022, it was determined that:

(1) your operations administrator failed to ensure  compliance with the current HM Plan(s); and

(2) 12 months had elapsed since the effective date of the plan.

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

Your operation received a medium-weighted citation in a pattern/trend category on September 6, 2022.  Specifically, the operation was cited for 748.3301(a)(2) Physical Site- Buildings must be clean and in good repair. The operation met compliance on September 22, 2022.

- Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring.

Correction Narrative: An HM extension was approved effective 10/7/2022.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your CPA/GRO in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 748.535(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is 4/2/2023.


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

raw_content: One of the bathrooms was observed to be clogged and had fecal matter in it. A window was observed not to be in good repair and was pushed out on one side.


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

Correction Narrative: 6 children reported that profane language and belittling remarks were made by the staff. Four children were interviewed regarding profane language and belittling remarks. There were no concerns.


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

Correction Narrative: Restraint was initiated due to child refusing to follow directives from staff. Four children were interviewed regarding inappropriate restraints. There were no concerns.


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

Correction Narrative: Staff engaged in physical discipline by slamming child on a table due to child refusing to follow instructions. Four children were interviewed regarding inappropriate restraints. There were no concerns.


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

Correction Narrative: Restraint was initiated in a non-emergency situation due to child refusing to release a lego.  Four children were interviewed regarding inappropriate restraints. There were no concerns.


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: Staff member engaged in a power struggle with a child in care due child refusing to release a lego. Staff member slammed child on a table during the incident.


summary: 748.1213(b) - Information For Caregivers-Op must inform caregivers of child's special needs. ie medical or dietary needs/conditions. Doc that info was shared.

raw_content: The operation is not sharing any information regarding the child's needs such as coping skills and triggers there is also no documentation available that anything has been shared to the caregivers. The last documentation reviewed and available for caregivers was from 12/14/2020.

Correction Narrative: A physical site inspection resulted in an observation of staff being able to locate a binder in the staff's office that contained each child's de escalation preferences and each staff member has signed confirming that they read them.


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 walkthrough, it was observed that sofa chair in dayroom spring was broken, causing the chair to lean.

Correction Narrative: Leadership emailed picture of sofa chair being removed from inside the operation and placed on the curb for dump truck to pick-up.


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 walkthrough,  it was observed that a staff that is not counted in ratio was watching a group of children.


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

raw_content: Staff member was overheard telling the resident that he was a liar and not credible. In the interview with staff member, staff member stated there was a pattern forming with the child having an attraction to his older roommates. Staff member even admits to bringing in the children and putting them against one another. However, he continued to put him with similar roommates, and failed to tell his therapist.

Correction Narrative:
All Administrative staff will document any conversatios
that are held with residents and with other individuals about residents, to ensure that nothing is misunderstood and to validate what was stated during the conversation. The document will be signed by resident (if applicable) as well as any other party that is present (if applicable). Documentation will be kept in Binders in the Administrative Offices.


summary: 748.2553(2)(B) - EBI Release-Child released from personal restraint within one minute of implementation of a prone or supine hold

raw_content: Documentation shows a child was held in a prone position for 2 minutes.

Correction Narrative: The staff involved completed retraining for EBI.  The op conducted a staff meeting on May 20, 2022 and focused on EBI documentation; specific to, ensuring that the type of containment and length of time is also documented in the incident report.


raw_content: It is determined that a child was found outside the home, close to the street with no supervision.

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


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

raw_content: Children that were interviewed stated that  a staff member talks to them rudely and at time uses profane language.

Correction Narrative:
. All staff were re-trained on   subjecting a child to abusive or profane language and the standard.
2. A suggestion box was ordered and will be made available upon arrival for residents to express their concern/complaints anonymously as well as any issues that they have.


summary: 748.3301(g) - Physical Site-The grounds must be free of garbage & debris & maintained in a sanitary manner

raw_content: There were several areas on the physical grounds that require attention such as the fence being broken in several areas, large trash that include furniture, trash, ant beds, and large rocks.

Category: Physical Site


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 diagrams observed do no include a designated shelter inside location nor an identified meeting place on the outside of the operation.


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

raw_content: There was a black-two drawer file cabinet in the medication closet without a lock; preventing the "overflow" medication from being double locked.


summary: 748.3273(4) - First Aid Kits-Each one must contain cotton balls

raw_content: Most of the first aid kits were observed missing several of the required supplies such as: cotton balls, adhesive tape, and thermometers.


summary: 748.3441(a) - Food Preparation-Food & drinks must be of safe quality, stored, prepared, distributed, & served under sanitary & safe conditions

raw_content: There were three packages of chicken fajitas with a use by date of 02/17/2022.


raw_content: Five out of five children interviewed stated staff members curse at them.

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

Correction Narrative:
An email was received from the administrator stating the following: Administrator will conduct a Mandatory Emergency Staff Meeting on 3-15-22 to address this Citation.  Administrator will train/re-train staff on the importance of the standard and the ramification of not following the standard.  It will further be discussed in detail, how the inappropriate verbiage can impacts the residents.

Brief interviews were conducted with staff and residence; there were no additional disclosures of concerns.


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: Upon reviewing child's file, the TB test was missing from immunization list.

Correction Narrative: The TB test that was missing in the child's file was completed and was sent via email.


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

raw_content: Two bottles of medication was observed in the staff room; not in the medication container where medication is kept.


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

raw_content: An altercation between two children that resulted in LE being called, was not reported to licensing.

Correction Narrative: The operation emailed a corrective action plan so that they are aware of what needs to be reported to liscensing.


raw_content: Four of six children interviewed stated staff used profanity to or around them. Three of six children stated Supervisory Staff use abusive, profane and threatening language towards children in care.

Correction Narrative:
Client interviews were conducted and three of three children denied being subjected to staff that were verbally degrading or using profanity. Staff were consulted about their participation in a staff meeting to discourage inappropriate language in the presence of children in care.

An email was received from the administrator stating that a zoom staff meeting was held to address the minimum standard violation and discourage any further behaviors.


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

raw_content: Two medication record logs were missing pills that are not accounted for. One Log has 20 pills listed but only 18 pills were found and the second log had 23 pills listed and only 22 pills accounted for.

Correction Narrative: An audit of the logs were conducted and it was found the pills were administered but was not documented. 1. medication error was form was completed. 2. Medication audits will be conducted twice weekly.


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

raw_content: Two of three bathrooms contained no hand washing soap. Three of three bathrooms did not contain any approved hand drying agent.

Correction Narrative: All bathrooms were observed to have electronic hand drying devices, toilet paper and hand washing soap.


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

raw_content: One child record reviewed did not include the priliminary service plan.

Correction Narrative: Operation submitted via email the preliminary service plan.


raw_content: A bed board was broken on the bottom bunk in bedroom 1 creating a risk to children in care.

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

Correction Narrative: The broken bed board was repaired on 4-20-21 by Maintenance.  Going forward New Hope Youth Center will continue to conduct Walk-Thru Inspections twice a week to ensure that all needed repairs are seen, documented and repaired in a timely manner.


facility_name: A Better Choice ABC LLC

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

raw_content: Police responded at a GRO for an altercation between children and both children were issued tickets for assault family violence.

Correction Narrative: Compliance was met and was discussed with Michael Atwater during an inspection at the agency on 3/11/26. The administrator, Terry Atwater, sent their PowerPoint training document and blank test on 3/9/26 via email. They said that on Monday 3/2/26, they discussed the requirements for serious incident reporting with the staff to ensure they understand the requirements. They will conduct additional trainings with staff next week and will be completed by the 3/22/26.


summary: 748.1205(a)(3) - Admission Documentation-Include names, addresses, phone numbers of bio or adoptive parents, unless parental rights terminated

raw_content: A child's file reviewed did not have the child s bio parent s names or contact information documented in the file. It was also missing  the child s sibling's information.

Correction Narrative: Compliance was met when the administrator sent an email with a plan on how they will ensure all the information is included on their admission records.


summary: 745.8641 - Requirements during probation

raw_content: Condition #1 is met Condition #2 is met Condition #3 is met Condition #4 is met Condition #5 is met Condition #6 is not met. Two new placements do not have an initial audit completed. The children ae not emergency placements and have been in placement for almost a month.  Condition #7 is met

Correction Narrative: Compliance was met when the administrator sent an updated audit form that shows the requirement for what documents are needed before a child is officially placed at their operation.


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 current fire inspection was marked as a foster home and not a GRO. It was noted on the fire inspection that they housed 5 or less children.

Correction Narrative: Compliance was met when the administrator sent an email with the attached completed fire inspection.


summary: 745.635(3) - AP Background ck determination - If provisionally eligible w/conditions or eligible w/conditions you must restrict duties per conditions/restrictions

raw_content: A caregiver did not follow the conditions listed on their background check when the caregiver transported children.

Correction Narrative: Compliance was met when the administrator advised that they updated their audit checklist and ensure that conditions are reviewed. The employee is no longer working at the operation.


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

raw_content: The tile in the child's bathroom is cracked and is pulling up from the floor.

Correction Narrative: Compliance was met when they called in a maintenance request. Repairs are scheduled for 11/19/25.


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

raw_content: Two children did not sign their initial service plans.

Correction Narrative: Compliance was met when the Administrator sent an email stating that they are updating their audit sheet to ensure children sign their service plans.


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

raw_content: Children's documents were not in their record within the 30 day timeframe requirement.

Correction Narrative: Compliance was met with the Administrator sent a document stating that the Audit Tracking Sheet now includes Documentation showing that all resident binder requirements must be completed no later than 30 days.


summary: 748.505(b)(6) - Minimum qualifications for employees- Must have cleared pre-employment screening assessment.

raw_content: An employee file did not have reference checks or employment verifications in their record.

Category: Personnel

Correction Narrative: Compliance was met when the Administrator sent an email and said that Pre-employment screening (3 References) has been added to the Staff File Audit Checklist, which will be a part of the monthly Employee File Audit Checklist.


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

raw_content: Two children's files are missing information required in the section below 748.1337(b).

Correction Narrative: Compliance was met when the Administrator sent an email saying that they will start using the DFPS form.


summary: 748.723(b) - Volunteers and Contractors-Personnel record documents how volunteer requirements are met if person performs an employee function

raw_content: A contract employee does not have an employee file.

Correction Narrative: Compliance was met when an email was received from the Administrator stating that they created an audit tool to ensure they are compliant with records for all volunteers and contractors. The audit tool was sent.


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

raw_content: A contract employee did not have an eligible background check.

Correction Narrative: Compliance was met when the administrator sent the background request record showing that the individual's background was requested.


raw_content:
Condition 1 is met.
Condition 2 is not ready for review.
Condition 3 is deficient. This was corrected on 10/30 when they submitted a resume for a outside trainer. However, this was submitted late.
Condition 4 is not ready for review.
Condition 5 is not ready for review.
Condition 6 is met.
Condition 7 is met.

Standard Number / Description: 745.8641 - Requirements during probation


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

raw_content: Staff file is missing the form 2912.

Deficiency Narrative: Staff file is missing the form 2912.

Correction Narrative: Compliance was met when the administrator sent the corrected form. He also advised that they updated their audit check list.


summary: 748.949(b)(5) - Annual Training Documentation-Includes the length of the training in hours

raw_content: The length of training hours is not included on all training certificates.

Correction Narrative: Compliance was met when the administrator sent an email to advise that they reviewed all employee files and made corrections to the training certificates.


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

raw_content: The pre-employment affidavit for applicants were not completed before employees were hired and is missing information on the form.

Correction Narrative: Compliance was met when the administrator sent the corrected form. They also updated their staff binder audit check list to address this form.


summary: 748.911(a) - Each caregiver must have a current certificate of training with an expiration or renewal date in pediatric first aid with rescue breathing and choking

raw_content: Staff was missing the first aid trianing.

Correction Narrative: Compliance was met when the administrator sent a new first aid training certificate.


raw_content: The facility has a lot of dirt around the windows. There are cracked tiles that are also coming up. There is a hole in a step, broken window blinds, paint is peeling in a bedroom, a broken window, cracked walls, and black marks on a wall.

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

Correction Narrative: Compliance was met when the administrator sent photos of the step, window, and door on 9/20/25. Additionally, a follow up inspection was conducted on 10/22/25.


raw_content: Employee files were missing the required list five years of employment history, verification of employment and reference checks.

Standard Number / Description: 748.505(b)(6) - Minimum qualifications for employees- Must have cleared pre-employment screening assessment.

Correction Narrative: Compliance was met when the administrator sent an email stating that they have incorporated a screening process into their Staff Audit Process. They also completed the 3 reference screening check for the employee in question and placed it in his personnel binder. They will also have Management verify that the Employee Reference Checklist is completed.


summary: 748.303(a)(12)(A) - Serious Incident-Report to Licensing as soon as aware of a suicide attempt by a child

raw_content: It was discovered that a child attempted suicide and it was not reported to state wide intake. The child was also arrested during the same incident which is also reportable and was not reported.

Correction Narrative: Compliance was met when the administrator sent an email to advise that all employees and management have been retrained with regards to the process for communicating all Serious Incident Reports (SIR) and the critical nature of reporting Serious Incidents within the mandatory time frames. Mr. Terry Atwater also sent a read and sign document with signatures from all staff.


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

raw_content: Fire extinguishers are past due for their annual inspection.

Correction Narrative: Compliance was met when the administrator sent a photo showing the fire extinguishers were serviced. The administrator also stated that they are adding a reminder to ensure they are inspected timely in the future.


summary: 748.1215(b) - Admission Assessment-Professional level service provider must sign & date assessment, which must be in child's record

raw_content: A child did not have a completed admission assessment in their record.

Correction Narrative: Compliance was met when the administrator sent the admission assessment and a check list showing how they will ensure that the admission assessment is completed and, in the file, as required.


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

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

Correction Narrative: 6/23/25-Compliance was met when the Administrator notified that staff were provided with additional training materials and dialog to ensure that all youth in care adhere to a child's rights to be free of abuse, neglect and exploitation. A read and sign was also completed. On 7/2/25, an Inspection was conducted. A review of the compliance was conducted with the administrator.


summary: 748.2551(b) - EBI Implementation-The caregiver must act to protect the child's safety

raw_content: Caregivers did not intervene when children in care were injured during an altercation.

Correction Narrative:
On 6/21/25-Compliance was met when the Administrator sent notice that additional training has been implemented. They also have a read and sign.
On 7/2/25, an Inspection was conducted. A review of the compliance was conducted with the administrator.


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

raw_content: A serious incident report is missing the names of the staff involved.

Correction Narrative: 6/23/25-Compliance was met when the Administrator advised of additional training that was implemented to address this deficiency. On 7/2/25, an Inspection was conducted. A review of the compliance was conducted with the administrator.


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

raw_content: Caregivers did not provide adequate supervision to children which led to an altercation among children and resulted in a serious injury.

Correction Narrative:
On 6/23/25-Compliance was met when the Administrator advised of additional training that was implemented to address this deficiency.
On 7/2/25, an Inspection was conducted. A review of the compliance was conducted with the administrator.


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 was seriously injured, and the incident was not reported.

Correction Narrative: 6/21/25-Compliance was met when the Administrator advised of additional training that was implemented to address this deficiency. They also updated their serious incident form. On 7/2/25, an Inspection was conducted. A review of the compliance was conducted with the administrator.


summary: 748.753(c)(3) - Pre-employment Screening- You must document your assessment of the applicant's suitability to work with or around children.

raw_content: The employee's file did not include contact names and information for reference checks, reference checks and information required for the reference checks, and an assessment of applicant's suitability to work with or around children.

Correction Narrative: Compliance was met when the Administrator sent an updated template for employment verification and reference checks. He also advised that the individual was given a time frame to provide his proof of education. He did not provide the proof and was terminated.


summary: 748.363(1) - Personnel records-Include date of employment

raw_content:
The following information was missing from an employee file:
The date of hire, the proof of education, and a signed statement showing that they must document and report incident of child abuse/neglect

Correction Narrative: Compliance was met when the administrator sent a copy of an updated file cover which includes a space to enter the employee's date of hire. The administrator also sent a check list to be used for each employee file.


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

raw_content:
It was discovered that a child's medication count did not match the medication log.

During the follow up inspection, there was another medication that had a count that did not match the medication log.

Correction Narrative: Compliance was met when the administrator advised that they will implement a new system to include the child's initials on a log to show they took their medication or refused to take it.


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

raw_content: During the follow up inspection, it was discovered that the medication record was not updated within two hours of administering the medication.

Correction Narrative: Compliance was met when the administrator discussed that he met with staff and discussed the requirement to ensure records are documented timely.


raw_content: The pill count for multiple children's medications did not match what was documented on the medication log.

Correction Narrative: Compliance was met when the administrator sent a medication error template the medication error policies, and medication error disciplinary certificate.


summary: 745.635(3) - AP Background ck determination - If provisionally eligible w/conditions or eligible w/conditions you must restrict duties per conditions/restrictions

raw_content: During the inspection it was determined that a staff is not following the restrictions placed by CBCU.

Correction Narrative:
Compliance was met when the operation updated their staffing schedule to ensure the staff with the conditions on their background is meeting the conditions.
The operation also submitted a plan to address the changes they made to ensure compliance with this standard.


raw_content: It was discovered that a child's medication count did not match the medication log.


summary: 748.313(3)(B) - Serious Incident child absent without permission-document notice to parents and law enforcement about child's absence and subsequent location/return

raw_content: The date and time the incident was reported to the legal parent and/or law enforcement was notified was not noted on a serious incident report.

Correction Narrative: Compliance was met when the administrator sent an updated serious incident template to show how they are going to ensure this information is captured for all future incidents. In addition, the operation will perform an audit on reports as well.


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

raw_content: The name and signature of the person dispensing the laxative was not provided only the initials were present.

Correction Narrative: Compliance was met when the Administrator sent an email that included the following plan: Management will audit (and document) the medication log once weekly and verify that all current staff have completed the proper signing on the back.


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

raw_content: A caregiver has transported children while driver s license is expired.

Category: Transportation

Correction Narrative: Compliance was met when the administrator sent their plan of ensuring compliance with this standard. In addition, the administrator stated that they are also transitioning to the Extended Reach Platform. Reminders of all upcoming expiration dates will be inputted and audited by ABC LCCA.


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

raw_content: A child was not given their morning medication.

Correction Narrative:
Compliance was met when the administrator sent the following plan: Management will do a daily audit of
the medication log to ensure all residents have been given their prescribed medication. Management created a form to track the date and time of the daily audit. This form was sent to the inspector.


raw_content: During the walk through when examining the medication logs, the pill count for one of the children's medications did not match what was documented on the child's medication log.