raw_content: During the walk through for the investigation inspection, one child's medication logs were filled out for the rest of the month. The date of the inspection was on 11/26.

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


state: TX

facility_name: A Better Choice ABC LLC

summary: 748.2003(b)(2) - Administration of Medication-Store medication in the original container unless there is an additional container with the same label & instructions

raw_content: During the investigation inspection, it was discovered that some of a child's medications are being stored in a weekly pill container outside of the original container.

Category: Individual Standards Evaluated

Standard Risk Level: Medium High

Corrected at Inspection: No


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 investigation inspection, it was discovered that staff did not adhere to the restrictions placed by CBCU.

Standard Risk Level: High


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

raw_content: There were no signatures on the preliminary service plans that were reviewed.

Standard Risk Level: Medium

Correction Narrative: Compliance was met when the administrator sent a document that shows how they will keep track of items needed for the service plan.


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

raw_content: During the investigation inspection, the unauthorized absence log was not provided to licensing staff upon request.

Correction Narrative: Compliance was met when the administrator sent an email statin that he will ensure that the log is kept at the operation and made available to review when requested. He also stated that they will have it updated in Extended Reach once they go "live" with that platform.


summary: 748.1381(1) - Service Plan Review-If child not receiving treatment services, review at least 180 days from date of last service plan

raw_content: It was determined that the service plan reviews were not being conducted for a child in care placed at the operation for more than 180 days.

Standard Risk Level: Medium Low

Correction Narrative: Compliance was met when the administrator sent a tracking chart showing how they will ensure service plans are updated.


summary: 748.311(3) - Serious Incident Documentation-Includes name, age, gender, and date of admission of the child or children involved

raw_content: On both of the incident reports reviewed, neither one documented information about the other child involved.

Correction Narrative: Compliance was met when the administrator sent the updated serious incident template.


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

raw_content: During the review of children's records, it was discoverd that the children's service plans were not in the child's file.

Standard Risk Level: Low

Correction Narrative: Compliance was met when the Administrator sent a template check list that is to be included in all children's files. The check list was reviewed and appears appropriate.


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

raw_content: The following informaton is missing from the serious incidet reports: The address of the operation, the phone number of the operation, the time of the incident, the age of the child, the gender of the child, the placement date of the child, and the resolution of the incident.

Correction Narrative: Compliance was met when the Administrator sent the corrected SIR template.


summary: 745.619 - Background Check Requirements - Submit All Identifying Information

raw_content: An out of state back ground check was not completed for an employee who moved to Texas in 2020.

Correction Narrative:
The agency has deactivated the employee background check and will re-run the background check requesting the out of state background. The employee has been taken off the schedule until the out of state background check is completed. The operation is unable to access their MyDAP at this time to re-run the background check and have an IT ticket 8239582
The operation has created a document that will require multiple members of management to verify that all requirements were met for requesting the correct background check.


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

raw_content: One of the three employee files did not have the contact attempts made prior to being hired.

Category: Personnel

Correction Narrative: The operation submitted an email stating that they will make sure that they will be using the pre-employment screening form to ensure that they are conducting the reference checks previous to hiring potential employments.


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: Two children in care, both age 14 were involved in inappropriate sexualized behavior while placed at the operation, and the caregiver was unaware of the children's activity.


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

raw_content: A caregiver failed to provide appropriate supervision for two children in care which allowed the children to engage in inappropriate contact while placed at the operation.


summary: 748.1331(f) - Preliminary Service Plan-Implement and follow the preliminary service plan

raw_content: One of the two children at the operation were not supervised in accordance with the information that is described and documented in the child's information data.


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

raw_content: Both child files reviewed did not list the religion for the child in care in the admissions.

Category: Admission, Service Planning, Discharge

Correction Narrative: A copy of the new face sheet was recieved. A line for religion was added to the form.


summary: 748.125(d)(4)(A) - Suicide Screening- A screening tool must be administered at admission for each child 10 years of age or older.

raw_content: Both child files reviewed did not have the suicide prevention assessment for children age 10 and over. Both children are over the age of 10.

Category: Organization and Administration

Correction Narrative: A copy of the Columbia suicide prevention assessment was completed on 8/13/23.


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

raw_content: A caregiver fought and hit a child in care in the face.

Correction Narrative: The direct care staff involved in the altercation has been terminated. The operation has also conducted additional training specific to de-escalation. The operation submitted a copy of the training with the employees who attended the training.


summary: 748.311(1) - Serious Incident Documentation-Includes name of the operation, physical address, and telephone number

raw_content: The incident report did not have a physical address, telephone number or the name of the operation on the incident form.

Correction Narrative: The operation submitted a copy of the new form 2991 that they will be using. This is an HHSC form. Staff has been informed of the change and instructed on how it is to be filled out.


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

raw_content: It was determined that staff did not demonstrate self-control and maintain appropriate boundaries causing a child's behavior to escalate.

Correction Narrative:
         We re-visited our EBI Training with Staff and provided information from our Preventing Aggression and Physical Holds (PAPH) Training which included information on de-escalation of situations with residents.
         We reviewed with each resident their preferred method of de-escalation shared that information with our staff.
         We created a binder with each residents' information to better familiarize our staff with the tendencies of each resident. The Binder includes: (1) Resident Face Sheet, (2) Attachment A, (3) CPS Child Rights, (4) Childs' Plan of Service, (5) Placement Summary. Upon reviewing the documents, each staff/management personnel were required to sign a Read and Sign document acknowledging that they had read the documents and were familiar with the behaviors/tendencies of each resident.
         Each Staff/Management Personnel were required to review the de-escalation document: De-escalation, How You Can Help Defuse Potentially Violent Situations and Top 10 De-escalation Techniques and received a training certificate upon completion of training which is in their respective personnel files.
         We will have refresher training regarding De-escalation techniques every 6 months, and staff will receive a certificate upon completion.


raw_content: 17-year-old child in care with a history of aggressive behaviors was escalated by a caregiver resulting in a physical altercation and the child's arrest.

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


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

raw_content: One of the two childrens medication log did not match the number of pills in the pill packs.

Category: Medication

Correction Narrative: Going forward for the next 30 days will review medication log daily to ensure entries are correct. After the 30 day period the medication logs will be reviewed weekly to ensure compliance.


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

raw_content: One of the two files reviewed did not have the contact numbers of the siblings.

Correction Narrative: An additional email was sent on 6/5/23 requesting contacting numbers for resident's siblings and everyone on the approved contact list. ABC staff will follow up Monthly requesting this information, if it has not been received.


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 log did not have the cumulative totals listed. There was no medication log, The time, name of medication and dosage amount was llisted on the childs daily notes.

Correction Narrative: A copy of the new medication log was received which contains all the elements. The operation will be going to electronic files including the medication log. They are going to be using Extended Reach.


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

raw_content: One of the two employee files reviewed did not contain a job description.

Category: Reports and Record Keeping

Correction Narrative:
The operation created a check list that will be put at the beginning of each employee file. The check list all required documents and has a place for a check mark once the required document is received.
A job description was placed in the employee file.


summary: 748.363(10) - Personnel records-For each person who transports a child, include copy of valid driver's license or DPS driver's license check done in last 12 months

raw_content: Both employee files reviewed did not have the drivers license. One of them did not have the license or job description. The second employee file indicated that the employee would be assisting in driving, but did not have a vailid Texas driving license.

Correction Narrative: The operation created a check list that will be put at the beginning of each employee file. The check list all required documents and has a place for a check mark once the required document is received.


summary: 748.1205(a)(6) - Admission Documentation-Includes medication the child is taking

raw_content: The Admissions policy did not include the statement "medication the children are taking"

Corrected at Inspection: Yes


summary: 748.363(5) - Personnel records-Include copy of a cleared tuberculosis screening conducted prior to the person having contact with children in care

raw_content: Both employee files did not contain documentation regarding the tuberculosis screenng or results.

Correction Narrative: Both employees have scheduled their TB test screening. They will not have any contact with children in care prior to having a negative TB Screening Test on File and the results of their TB test will be placed in their respective folders upon receipt by ABC LLCA. At that point they will be allowed to have contact with children in care.


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

raw_content: Both employee files reviewed did not have the date of hire in the employee file

Correction Narrative: The operation created a check list that will be put at the beginning of each employee file. The check list all required documents and has a place for a check mark once the required document is receiveved.


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

raw_content: One of the two employee files reviewed did not have the background check requested.


summary: 748.161(b) - Fiscal requirements - Maintain complete financial records that comply with Generally Accepted Accounting Principles

raw_content: The operation supplied the updated financials for the 3 month and 12 month as well as a bank statement


facility_name: Wholeness Haven Inc.

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

raw_content: The author of an incident report, failed to document her involvement during a restraint of a child in care.

Correction Narrative:
Corrective Action:
1. Revised Incident report - The staff members involved were informed of the deficiency, and instructed to review and revise the incident report to accurately include the names of all involved and their role in the restraint. The corrected incident report was completed and placed in the childs records.

2. Retraining of Staff: On 11-5-2025, all staff received mandatory retraining covering Minimum Standard 748.311(4), Serious Incident documentation requirements, accurate completion of incident reports, and the importance of documenting all present along with their roles and actions. The training also reinforced factual and objective report documentation.


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

raw_content: An incident report was found to have inaccurate information. The date of the incident was incorrect. In addition, a caregiver named in the report was not present on the day of the incident.

Correction Narrative:
Corrective Actions
1. Staff members involved in the incident were informed of the deficiency and directed to review and revise the incident report to correct the date and remove the incorrect witness listed. The corrected incident report was completed and placed in the childs records.

2. On 11-5-2025, all staff received mandatory retraining on Minimum Standard 748.311(4), which included Serious Incident documentation requirements, and the accurate completion of incident reports.

3. Wholeness Haven is in the process of implementing a two-person audit to review all incident reports to ensure they meet Minimum Standard.


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: On 8/19/2025 a youth in care was transported to the hospital for medical evaluation for a hand injury. After clearance the youth was admitted to a psychiatric hospital for suicidal ideations & unsafe behaviors. This incident was not reported to Licensing.

Correction Narrative: Re-training: All administrative staff, supervisor and Shift Leads, were re-trained on what constitutes a serious incident report and the steps to take when a serious incident occurs. Training also entailed assisting in reporting the serious incident no later than 24 hours to the relevant parties (licensing, caseworker, contract manager and the hotline) without waiting on the administrator to do so.


raw_content: A staff member used derogatory language when addressing a child's behavior.

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:
The staff member has been retrained on using prudent judgement in her choice of words, when redirecting the youths served. Staff received refresher training on Trauma-Informed Care principles, emphasizing how tone and language can impact a youths emotional regulation and sense of safety. The retraining covered appropriate verbal interventions, de-escalation techniques, and the importance of maintaining professionalism at all times. Continued observation and supervision will occur to ensure consistent implementation of trauma-informed communication.
An in-person follow-up was conducted where children in care were interviewed; there were no further outcries of abuse/neglect.


summary: 748.505(b)(5) - Minimum qualifications for employees- Must complete a Pre-Employment Affidavit for Applicants for Employment.

raw_content: Multiple active employee files reviewed have no record of a Pre-Employment Affidavit for Applicants for Employment form.

Correction Narrative:
All Affidavits for the recently hired employees that were not notarized have since been notarized and placed in their binders. They have been labeled as Late entry.

Moving forward all newly hired staff will have their affidavit notarized on their own or at the facility (as there is a notary on site).

Wholeness Office staff have been trained to ensure that the signed and notarized affidavit is in the staff's binder prior to them starting the job.


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

raw_content: Multiple active employee records have an incomplete/unnotarized Licensing Affidavit for Applicants for Employment form.

Correction Narrative: All current employees have been given form 2912. Once completed they will be placed in each person's file with an indication of the late entry. Office staff have been trained on ensuring that this form is given to prospective staff in the application packet and placed in their files upon completion.


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

raw_content: There is no documentation of any practiced severe weather drills in the past 6 months.

Category: Safety and Emergency Practices

Correction Narrative:
Remedy:
A severe weather drill has been performed on June 19, 2025, and the event documented.

Staff and children have been informed of the severe weather drill requirements hence they are aware of the required behaviors and expectations during a drill.

 Moving forward severe weather drills will be added to the schedule to be performed every six months.


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

raw_content: Medication that was administered to a youth in care on 5/5/2025 at 7:00A was not recorded on the medication log until 5/6/2025 at 1:00P. Operation staff admitted during an inspection they failed to record administration of medication timely.


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

raw_content: A youth's initial service plan wasn't developed timely after their admission.

Correction Narrative: An email was received from the administrator that included a corrective action plan indicating a new treatment team has been hired and trained to adequately develop service plans timely. It also indicated the team will monitor these timeframes to ensure they are being met.


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

raw_content: Documentation to be reviewed were not in the youth's files timely although they were able to be provided.

Correction Narrative: An email was received from the operation's administrator which included a corrective action plan indicating administrative staff have received a refresher training in documentation and filing guidelines. It also indicated a monthly audit will be submitted to the administrator for review to ensure files are being maintained in compliance.


summary: 748.1531(a)(2) - Medical care-A child in care must receive medical care as needed for injury, illness, and pain

raw_content: A child in care was involved in physical altercation which resulted in two black eyes and no medical care was sought.


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

raw_content: Staff should manage the children effectively and try and prevent situations. Staff are allowing children that were involved in a physical altercation share a room.


summary: 748.2461(b)(1) - Short Personal Restraint-Caregiver may not use a prone or supine restraint

raw_content: Child in care was face down during restraint.


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

raw_content: Serious incident report was missing documentation, the incident of how a child in care received two black eyes was not documented.


summary: 748.4703(b) - Child/caregiver ratio-Caregiver must remain awake during night-time sleeping hours

raw_content: Based on interviews and documentation, an employee was found to be sleeping while taking care of children.

Correction Narrative: Interviews conducted with children in care confirmed staff has remained awake during night-time sleeping hours. Interviews with staff confirmed they received training on supervision.


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

raw_content: Child in care was given a different dose of medication as prescribed.

Correction Narrative: Interviews conducted with staff confirmed they were retrained on Medication Management and Medication Administration.


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

raw_content: Licensing did not have access to all active records during a monitoring inspection.

Correction Narrative:
Wholeness Haven RTC has implemented a revolving on call schedule to accommodate for emergency situations. The Wholeness Haven ON-Call divided bi-weekly between the Executive Director, Facility Administrator, and the facility Case Manager. In the event that an emergency arises, the Wholeness Haven facility Administrator will immediately appoint a designee to conduct administrative proceedings. The appointed designee will temporarily act with the full authority of Wholeness Haven Administrative Executive Management to include, but not limited to, access to all youth and staff files, documents requested by licensing, and any pertinent supportive policy documentation. In the event of an unforeseen environmental emergency, Wholeness Haven administration will contact licensing with ongoing situational updates and contingency plans.

Wholeness Haven utilizes Casebook for the upload and storage of digital records.  As casebook has an outstanding reputation for sustained reliability, the medium for communication may at times be unreliable to at best. Moving forward, in an effort to circumvent potentially unreliable systems communication, Wholeness Haven will have hard copy files readily available for submission and review.


summary: 748.3603(f) - Swimming-Fence gates to outdoor pool must have self-closing/self-latching hardware 60 inches from the ground and must be locked when pool not in use

raw_content: The gate surrounding the pool did not have self-latching hardware.

Correction Narrative: In-person inspection conducted. One self-closing/self-latching hardware was purchased and installed on the pool gate. The other gate already had a self-closing/self-latching hardware.


summary: 748.3601(9) - Swimming Pool-swimming area rules & emergency procedures must be posted at the swimming area & explained to the children

raw_content: There were no rules or emergency procedures posted in the pool area.

Correction Narrative: In person follow-up conducted.  Rules and emergency procedures were observed posted in the pool area. Emergency procedures have been created and made into policy, these have been explained to staff and youth in the facility. Concise emergency procedures have been posted in the pool area.


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

raw_content: There were no emergency evacuation diagrams posted in the home.

Correction Narrative: The emergency evacuation diagrams were printed but inadvertently not posted in the required areas due to oversight. These have since been posted in the message board downstairs and also posted upstairs.


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

raw_content: The emergency diagram showed three downstairs emergency exits that were locked from the inside, required a key to open, and two of the three exits were a pathway through the kitchen.

Correction Narrative: In person inspection was conducted. Both inside locks that required a key to open them at the front and back exits were removed. Staff were trained to ensure that evacuation exits are not locked with a key


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

raw_content: The permit was not posted anywhere at the operation.


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's right to be free of neglectful supervision was not upheld when staff did not implement policy and demonstrated disregard by leaving children in care unattended in the operation's van with the keys in addition to allowing the child to operate the vehicle. These actions demonstrated negligence.  This standard was found deficient as part of a DFPS Investigation.

Correction Narrative:
REMEDY:
1. The staff that did not utilize proper judgement has been terminated and no longer allowed to serve the youths as Wholeness Haven Inc.

2. Wholeness Haven created a transportation policy which includes but is not limited to; not leaving any youth in a vehicle unattended, not allowing access to the keys of the vehicle, and definitely not allowing any of the youths to drive.

3. All current staff have been trained on the new transportation policy. New staff will also be trained on the policy as they onboard.

4. All staff has been trained on properly supervising the youths that they are assigned each
day


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

raw_content: Staff did not follow the operation's policy when they left children unattended in the van with the keys.

Correction Narrative:
REMEDY:
1. All staff have been trained on not allowing any youth in care to drive the company vehicle
or any other vehicle regardless of whether they have a driver's license or not.

2. All staff has been reminded in writing that it is their responsibility to use prudent judgement in providing supervision of all youth in their care, so that all youths will be safe at the end of each shift. Staff has also been reminded to be proactive in supervising all youth by predicting hazardous situations with routine evaluations of a child's environment and
by being able to adapt to the growing and changing needs of children in care.


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

raw_content: Staff did not exercise prudent judgement when they allowed a child in care to operate a motor vehicle without a valid driver's license.


raw_content: Staff allowed a child to drive without staff supervision and left the van keys accessible, which later led to the van being stolen and crashed.

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

Correction Narrative:
REMEDY:
1. The key box which stores the keys to the vehicle has been removed from the kitchen area and placed in the office area out of the reach of all the youths.

2. All current staff have been trained on not laying any important keys around, but instead ensuring that the keys are placed in the designated key box in the office area for the
safety of all youth.

3. All staff have been trained on not allowing any youth to drive the company vehicle or any other vehicle.


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

raw_content: During the investigation it was found that a child's high risk behavior was identified at admission and a safety plan was not implemented to address that behavior.

Correction Narrative: An email was received from the operation with a copy of the safety plan created at admission for the child.


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

raw_content: During the investigation it was found that a child's service plan was not completed timely.

Correction Narrative:
Upon Admission into Wholeness Haven RTC. Each youth will receive a Preliminary
Service Plan within 72 hours. Once A child has been in the care of Wholeness Haven for 30 days,
the Treatment Director will send out the Invite Email for the Service Plan meeting 2 weeks in
advance of the meeting. As part of the Service Planning process, the Treatment Director will also
schedule the next Service Plan meeting notification by entering the respective dates into our data
base system called CaseBook. Once entered into the system, it will be recorded under the
Compliance Date tab. Once properly entered, CaseBook will generate an alert prior to the next
notification due date. Once the Service Plan has been completed, the date of completion will be
entered as well as the Service Plan effective date. Once the initial Service Plan process is complete
the, date of the next meeting request will be entered into CaseBook, as well as the next Service
Plan review date. CaseBook will automatically record this information in the compliance date
section and send out alerts prior to the dates as will be indicated by highlighting the respective
section in red. Wholeness Haven Administration will routinely review all information as it relates
to Service Planning Compliance and coordination to ensure deadlines are adhered to.


summary: 748.1349(a)(1) - Initial Service Plan-Give copy or summary of plan to child, when appropriate.  At minimum must give copy to child 14 years and older

raw_content: A child did not receive a copy of their initial service plan.

Correction Narrative: Upon completion of the Single Child Plan of Service, a copy will be sent to the Managing conservator (Caseworker) for their signature and the request will be documented in the youth's file. The Therapist, and or case manager will review the Single Child Plan of Service with the youth and have the youth sign the signature page. In the event a youth refuses to sign, respective staff will note that on the signature line. Subsequent attempts will be made to get the youth to sign the Service Plan. In the event of subsequent refusals, documentation of each attempt will be placed in the youths file as well as forwarded to the youth's Managing Conservator (caseworker). If the Service Plan is discussed with the youth and the youth refuses to sign, documentation of the discussion will be placed in the youths file as well as forwarded to the youths Managing Conservator (caseworker). The youths Service Plan will include documentation of the plan having been shared with the youth and the youth's parents or Managing Conservator and the youth response to service to date.


summary: 748.936(1) - Annual Training-  Caregivers must have EBI w/in 6 months from the date they last received the training if operation provides treatment services

raw_content: A staff member did not complete the required refresher EBI training.

Correction Narrative:
The staff in question is no longer employed at Wholeness haven RTC. Facility Staff have recently
had SAMA training on 8-31-2023. As part of the SAMA training, TBRI methods of intervention were taught
and also role played. Attending staff successfully passed the SAMA training and demonstrated effective
TBRI techniques. All staff have been retrained on the specifics listed in their job description as well as THHS Minimum Standard 748.1101(b)(1)(B). Staff have been trained on child rights as it relates to standard in 748.1101(b)(1)B)


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

raw_content: Staff was observed on video attempting to wrap their arms around a child's neck. Staff was also observed pushing the child to the floor.

Correction Narrative: A follow-up inspection was conducted on 10/25/2023. The staff in question is no longer employed at Wholeness Haven RTC and the victim was discharged from the operation 8/11/2023. Administrator reports Staff have recently had SAMA training on 8-31-2023. Copies or certificates were requested. As part of the SAMA training, TBRI methods of intervention were taught and also role played. All staff successfully passed the SAMA training and demonstrated effective TBRI techniques. It has been stressed to staff the importance of remaining calm while also maintaining prudence and self-control, even under extreme provocation. Staff have also been instructed to notify supervision to request a break if a break away from the situation is needed. It has been emphasized that all staff need to be aware of their own limitations and not be afraid to ask for a break or assistance. The operation is currently in the process of moving locations and plans to hire majority new staff in an attempt to change's the operation's culture.


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

raw_content: Staff was observed hitting and punching a child on video.

Correction Narrative: A follow-up inspection was conducted on 10/25/2023. The staff in question is no longer employed at Wholeness Haven RTC and the victim was discharged from the operation 8/11/2023. Administrator reports Staff have recently had SAMA training on 8-31-2023. Copies or certificates were requested. As part of the SAMA training, TBRI methods of intervention were taught and also role played. All staff successfully passed the SAMA training and demonstrated effective TBRI techniques. It has been stressed to staff the importance of remaining calm while also maintaining prudence and self-control, even under extreme provocation. Staff have also been instructed to notify supervision to request a break if a break away from the situation is needed. It has been emphasized that all staff need to be aware of their own limitations and not be afraid to ask for a break or assistance. The operation is currently in the process of moving locations and plans to hire majority new staff in an attempt to change's the operation's culture.A follow-up inspection was conducted on 10/25/2023. The staff in question is no longer employed at Wholeness Haven RTC and the victim was discharged from the operation 8/11/2023. Administrator reports Staff have recently had SAMA training on 8-31-2023. Copies or certificates were requested. As part of the SAMA training, TBRI methods of intervention were taught and also role played. All staff successfully passed the SAMA training and demonstrated effective TBRI techniques. It has been stressed to staff the importance of remaining calm while also maintaining prudence and self-control, even under extreme provocation. Staff have also been instructed to notify supervision to request a break if a break away from the situation is needed. It has been emphasized that all staff need to be aware of their own limitations and not be afraid to ask for a break or assistance. The operation is currently in the process of moving locations and plans to hire majority new staff in an attempt to change's the operation's culture.


raw_content: A video was observed of a staff attacking a child which led to a physical altercation between the staff and child.


raw_content: A staff was observed inappropriately disciplining a child and attempting to place the child in a chokehold, this also included pushing and shoving the child to the ground.

Correction Narrative: RCCR conducted a follow-up inspection on 10/25/2023. The staff in question is no longer employed at Wholeness Haven RTC and the victim was discharged from the operation 8/11/2023. Administrator reports Staff have recently had SAMA training on 8-31-2023. Copies or certificates were requested. As part of the SAMA training, TBRI methods of intervention were taught and also role played. All staff successfully passed the SAMA training and demonstrated effective TBRI techniques. It has been stressed to staff the importance of remaining calm while also maintaining prudence and self-control, even under extreme provocation. Staff have also been instructed to notify supervision to request a break if a break away from the situation is needed. It has been emphasized that all staff need to be aware of their own limitations and not be afraid to ask for a break or assistance. The operation is currently in the process of moving locations and plans to hire majority new staff in an attempt to change's the operation's culture. Photos of the operation's new location were taken. The rooms were measured to determine capacity.


summary: 748.685(b)(4) - Caregiver responsibility - when deciding how close to supervise take into account the surrounding circumstances, hazards, and risks

raw_content: Caregivers failed to properly supervise a child in care who was exhibiting high risk behaviors.

Correction Narrative:
When supervising youth who display high risk behaviors staff will critically evaluate the surrounding environment with consideration to circumstances, existing as well as potential hazards and risks. When assessing surroundings for safety, staff will ensure that there is no potential risk of harm by way of location or proximity to youth. When a youth is placed on a special status watch, staff will ensure that no other duties are being performed at that time as it may distract from optimal supervision. Staff will also consult with administration if the selected area may for any reason be in question or possibly present a potential risk.

An in-person follow-up was conducted at the operation on 12/1/2023. Staff/child ratio was observed in compliance.  Staff was observed as alert and attentive. Staff checked in on clients that were in their rooms every 10-15 minutes.


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 child in care displayed warning signs to a staff member and a screening being done was not recommended.

Correction Narrative: A suicide risk screening will be administered immediately if a child of any age displays warning signs of suicide that necessitate a suicide screening be conducted. The Suicide Screening Too used will be The Columbia-Suicide Severity Rating Scale(C-SSRS). The suicide screening will be done in a manner that protects the youth's privacy. All staff will be retrained on the Prevention-Suicide Risk Screening methods and criteria for administration.


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

raw_content: Review of kids in care medication administration records revealed medications were not administered as prescribed.

Correction Narrative: We have added several layers of redundancy to our medication audit and review system to ensure optimal quality control. The facility administrator and the facility executive director audit the medication daily with each on alternate days. The facility administration also audits the medication daily before and after the medication has been administered. The facility administration also periodically supervises the medication administration process. The facility Staff Supervisor along with either the facility executive director or the facility administrator oversees the bi-weekly psychiatric medication review to ensure optimal accuracy in interpretation and communication of all pertinent information concerning the youths medication. The accurate information, as well as updated orders, if applicable, is then immediately disseminated to all staff. Due to possible frequent hospitalizations, the psychiatrist is also provided with the current status of the youths medication, its effect, the dosage and count as an added layer of quality control. If at any time a discrepancy is discovered, a plan of action will be put in place to address the specific circumstances and to prevent reoccurrence.


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

raw_content: Six reviewed medication records to not document the reason the child's medication is prescribed.

Correction Narrative: We have assigned a designated staff to be in charge of medication quality control measures, as well as retrained staff on medication count and documentation. We have revised our medication count record to use the picture of the blister pack as a method of recording accurate medication counts as it contains all of the required information. For the youth who have pill bottles, we will use our revised medication administration record until we are able to transition to blister packs.  Wholeness Haven Executive Management will audit the medication count and medication log twice a week.


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

raw_content: The recreational calendar reviewed during inspection does not include both indoor and outdoor daily activities.

Category: Recreation Activities

Correction Narrative: Remedy: We have revised our rotating activity calendar to include a variety of both inside and outside activities for every day of the week.


summary: 748.2151(c)(2) - Medication record - must include prescribing health-care professional's name

raw_content: Six medication records for children were observed without documentation of the prescribing physician.


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

raw_content: Seven medication records reviewed did not have an accurate pill count documented.

Correction Narrative: Remedy: We have assigned a designated staff to be in charge of medication quality control measures, as well as retrained staff on medication count and documentation. We have revised our medication count record to use the picture of the blister pack as a method of recording accurate medication counts as it contains all of the required information. For the youth who have pill bottles, we will use our revised medication administration record until we are able to transition to blister packs.  Wholeness Haven Executive Management will audit the medication count and medication log twice a week.


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

raw_content: 2 staff files and 1 child file were reviewed. Each file contained paperwork that was incomplete.

Correction Narrative: Personnel shall be responsible for verification that all required forms and signatures are in in each file. Additionally, another staff is in hire process. Duties of this employee shall include compliance review of employee and child records to ensure all required documents are present and complete.


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

raw_content: There were damage found with the fencing, security of the perimeter and damaged outside.

Category: Physical Site

Correction Narrative: The agency provided an updated paperwork with a work order on they fixed the fences around the property to. A copy of the policy will be available in Share point.


summary: 748.111(14) - Child-care policy - Procedures for routine and emergency diagnosis, including treatment of medical and dental problems

raw_content: During the application inspection the policy for medical care was missing. The mock file did not show the children had received medication from the date they entered the facility. Pregnancy needs for girls was void since the agency doesn't take females. Primary medical needs not listed in the policy.

Correction Narrative: The agency provided an updated policy which gives descriptive details of how they will handle emergency treatment for all children. A copy of the policy will be available in Share point.


raw_content: The records/documentation were not consistent, accurate, or completely filled out on the paperwork from the operation during the inspection.

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

Correction Narrative: The agency is aware that they must keep all documents and records updated at all times to ensure accurate information.


summary: 748.113(1) - EBI policy - a complete description of EBIs that you permit caregivers to use

raw_content: During the following application the agency didn't list the types of restraints that will be administered. A complete description of the TBRI information is needed.

Correction Narrative: The agency provided an updated policy which gives descriptive details of how they will use TBRI as a restraint. A copy of the policy will be available in Share point.


summary: 748.3109(b) - Smoke Detector-Batteries must be changed annually or sooner, as required to maintain operable smoke detector units

raw_content: The smoke detectors were sounding off on both levels . The detectors needed to have new batteries.


facility_name: STARR Resiliency Agency

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

raw_content: A child in care who had recently been discharged from an inpatient mental institution due to self-harming behaviors was permitted access to a bedroom with a known safety hazard. The bedroom door had a broken doorknob that locked when closed, preventing staff from gaining immediate access to the room. While staff were locked out and unable to supervise or intervene, the child self-harmed.

Correction Narrative: All of the bedroom doors and closet doors in the facility do not lock anymore. For children with a tendency to self-harm they check in every few minutes while they are in the bathroom.  All sharp objects are kept locked up and children do not have access to them without staff actively supervising the use of them.


raw_content: During the review of records 2 staff records did not have the pre-employment affidavit and the  pre-employment screening assessment was not filled out.

Correction Narrative: Proof that the operation has the affidavits was sent via email. The operation will make sure to keep records in the office in order to have them easily accessible.


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: An incident involving a child being arrested was not reported to licensing.


summary: 748.363(6) - Personnel records- Include copy of a cleared tuberculosis screening conducted prior to the person having contact with children in care.

raw_content: During a records review two staff records did not have a copy of a TB test on file.

Correction Narrative: The operation will keep all records in the office for now on in order to have them easily accessible.


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

raw_content: During a records review, two staff files reviewed did not have the notarized Licensing Affidavit for Applicants for Employment form.

Correction Narrative: The operation has the affidavit, and the operation will be keeping all records at the office in order to have the records easily accessible.


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

raw_content: Caregiver responsibilities were not met when the operation was unaware they left a childs only inhaler at the school for an unknown amount of time. The child is diagnosed with asthma and this specific need must always be readily available to the child in case of an emergency.

Correction Narrative:
Inspection #4041318 was completed by the rep of the operation to ensure compliance.
It was explained when a child is accepted, if they require an inhaler, a second inhaler will be requested at their 3 day visit or as soon as possible. By doing so, one inhaler can be left at school and the other at the residence.
(Also received via email on 2.3.25)


summary: 748.1661(c) - Tobacco Products-Adult may only smoke tobacco products, e-cigarettes, or vaporizers on premises at a safe distance from child living area

raw_content: A nighttime direct care staff member admitted stepping outside the front door of the children's living area to use a vaporizer while the children are asleep.


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

raw_content: A direct care staff was found asleep and admitted to being asleep at night with the home unlocked.


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.


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

raw_content: No witness children were noted in the incident report.

Correction Narrative: The administrator will review the incident report for accuracy prior to the document being placed in the child's file.


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

raw_content: The operation was given a deadline for sending records by 12/20/2024 at 5PM. Records were not sent and received until 12/23/2024.

Correction Narrative: The operation has added one more staff responsible for record requests. The staff members information has been added to the main page of the operation in CLASS.


summary: 748.1101(b)(4)(A)(iv) - Children's rights-Free from being denied food, sleep, a bathroom, mail, or family visits as punishment

raw_content: Five children interviewed stated that a caregiver threatened that a child/children could not eat dinner unless the child/children took a shower.

Correction Narrative: The staff members that were interview, stated Ms. Octavia conducted a meeting that involved the children Bill of Rights.  They were instructed how to properly interact with the children in care. Children are not to be threaten or belittled. The care of children and their safety should be the top priority of all staff members.  Staff stated they read the Child Bill of Right out loud, discussed when it means and how it should be implemented.


summary: 748.1433(a)(1) - Discharge-Involve in planning child's non-emergency discharge or transfer at least one of the child's current caregivers

raw_content: Follow up was not provided by the original compliance of 7/12/2024.

Correction Narrative: A discussion was had with the administrator and program director about the standard. In the future the operation will involve the child's current caregivers in the non-emergency discharge.


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

Deficiency Narrative: Follow up was not provided by the original compliance of 7/12/2024.

Correction Narrative: A face-to-face discussion was had with the administrator, Octavia Reed, regarding the ongoing issue with this standard. She was provided with the operation to go on a POA. She stated she would need some time to accept the POA or not. It was explained to her that if she did not accept the POA then the operation would go on expedited inspections.


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

Correction Narrative: A discussion was held with the Director and administrator about the components missing in the child orientation. The standard was explained in detail. They took notes and stated that going forward they would make sure to include everything in the child orientation.


summary: 748.311(1) - Serious Incident Documentation-Includes name of the operation, physical address, and telephone number

raw_content: The follow up was not provided by the original compliance date of 7/12/2024.

Correction Narrative: A face-to-face discussion was had with the Administrator and Program Director about the deficiency and how follow up needs to be completed timely. In the future they will make sure to include all of the necessary components in the serious incident reports.


summary: 748.1211(a) - Parent Orientation - At admission you must provide certain policies to the parent placing the child

Correction Narrative: A discussion was held with the Director and Administrator about the standard. The standard was explained in detail and examples were provided during the discussion. It was mentioned that they were not aware they had to do a parent orientation with children in care. The definition of parent was explained and how legal guardians fall under that definition. Going forward they will include CPS workers in in the parent orientations.


summary: 748.941(c)(3)(A) - Training Criteria- Training must require each participant to demonstrate knowledge and competency of the EBI training material in writing.

raw_content: The operation's administrator stated the records for EBI written test gets shredded and that the operation does not keep record of them, therefore, there is no record showing the staff member took a written test.


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

raw_content: A staff member of the operation did not have a pre-employment drug screening.


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

raw_content: The incident report was not consistent with the interviews of staff regarding the incident that occurred.

Correction Narrative: SRA Administrator will inform Direct Care staff that all incident reports will be true, current, and accurate according to the event that occurred. Staff should be able to verbalize accurately their written statement or report.


raw_content: It took the operation eight days to provide requested documentation.

Correction Narrative: The operation is currently on plan of action and 748.399(a) is noted as an area of concern in the plan of action. The administrator is responsible for ensuring records are being made available in a timely manner.


raw_content: The information documented in the serious incident report did not align with the information gathered from interviews with children and staff.


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

raw_content: The parent of a child with sex trafficking history was not made aware immediately of the child's unauthorized absence. The child eloped at 6:19PM and the parent was not notified until 7:31PM.

Correction Narrative: SRA will train staff that when a child, who is a confirmed victim of sex-trafficking, elopes from the parent/guardian/caseworker will be notified immediately, after contacting the local police agency.


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 documentation did not include the time and date when the children's parents and the relevant law enforcement agency were notified. Furthermore, there was no record of the names of the individuals contacted.

Correction Narrative:
SRA will have an addendum to the SIR which will include:
1.      Efforts made to locate the child:
2.      Date and Time of notification to:
a.      Parent/Guardian Date-_____________ Time of notification ______________am/pm
                                                              i.      First Attempt ________ Second Attempt__________ Third Attempt________
b.      Law Enforcement Date-_____________ Time of notification-_____________ am/pm
c.      Intake/Hotline: Date-________________Time of notification=_____________am/pm
3.      Date and Time Child returned to Facility
4.      How long was the child away from the facility? ______________________
5.      If a child 202020is away longer than 24 hours document all events that occurred during the child's return.


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

raw_content: A child in care with sex trafficking history was allowed outside without supervision. The service plan specifically documents the child requires "visual and auditory" supervision while at the operation. Additionally, it documents the child has a "history as a victim of sex trafficking", which "makes her more susceptible to elopement and unsafe sexual activities."

Correction Narrative: The Program Director will ensure that trafficking history is included in the service plan and the Administrator is responsible for training and informing staff of the child's current level of supervision. The supervision plan will be shared with staff concerning all high-risk children residing within the facility.  As the child's level for supervision changes, updates will be made to their service plan.


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

raw_content: A child's room was searched, however, there was no documentation completed.

Correction Narrative:
Administrator will conduct training on how to conduct and document searches in the child's record. The following information must be included when documenting the results of the search:
 1) The date of the search:
2) The name of the child:
3) Reason for the search:
4) A description of what you searched:
5) The clothing removed, if applicable:
6) The name of the caregivers conducting the search:
7) The name of the witness, if applicable:
8) The results of the search:
9) The resolution of the issue with the child, including increased supervision, additional counseling, or disciplinary consequences:


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

raw_content:
A Direct Care Staff is currently working at the operation without an approved background check.

The staff's background check was ran on 7.26.24. The staff was present during an incident on 7.27.24. The background check has not been completed as of 8.15.24. Additionally, it was found the staff worked 8.11.24 and is scheduled for 8.16.24.

Correction Narrative: An email was received from the operation on 9.5.24. It was explained prior to employment with STARR, no person will be allowed to be present at the operation. Background checks will be checked by the Administrator or Program Director prior to anyone being allowed at the operation. Ms. Dumas background indicates she is inactive on the peoples list.


raw_content: Three children's records did not have a parent orientation.

Standard Number / Description: 748.1211(a) - Parent Orientation - At admission you must provide certain policies to the parent placing the child


summary: 748.2151(c)(4) - Medication record - must include medication name, strength and dosage

raw_content: The medication log for a child is missing the medication dosage and time administered.

Correction Narrative: The operation is going back to paper medication records until they figure out how to track medications on their electronic system. 3 medical records were verified and in compliance.


raw_content: All four incident Reports reviewed did not include the telephone number of the operation.

Standard Number / Description: 748.311(1) - Serious Incident Documentation-Includes name of the operation, physical address, and telephone number


summary: 745.621(a)(2) - AP Initial background checks submitted - At the time you hire someone

raw_content: Background checks for two employees were not conducted by the operation.


raw_content: The operation was not able to provide the emergency drill records during the inspection.


raw_content: The discharge summary record for a child was not filled out. It was also missing singnatures for all parties that should of been involved.

Standard Number / Description: 748.1433(a)(1) - Discharge-Involve in planning child's non-emergency discharge or transfer at least one of the child's current caregivers


raw_content: Two out Three childrens records reviewed were missing several policy components to include the emergency behavior interventions.

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


raw_content: Documentation was requested 3 times within a 3-week period from the operation.

Correction Narrative: Karen Daniels, Program Director will have access to the records in the absence of Octavia Reed, administrator, in order to provided records in a timely manner.


raw_content: RCI had to request documents multiple times within a three-week period before receiving documents.

Correction Narrative: During an in-person meeting for a warning letter regarding compliance with making records available to licensing upon request the operation was given the opportunity to go on a voluntary action plan. The operation was given until 8/28/2024 to decide. It was explained that if the operation refused the POA then they would be put on expedited inspections for a period of time.


raw_content: The operation failed to submit a corrective action plan addressing compliance for not submitting records to RCCR until five days after the original request date, despite RCCR sending multiple reminders.

Correction Narrative: The operation has hired a case manager and an administrative assistant, to make records available upon request, review, or reproduction to RCCR. Their contact information was provided to RCCR.


raw_content:
On 11/03/2023, during the in-person investigation records were requested but told that they would be provided via email and sent to the RCCL Inspector.
On 11/15/2023, an email was sent to the operation requesting records and that they needed by the end of the day on 11/17/2023. On 11/16/2023, due to not receiving a reply from my previous document request a reminder email was sent requesting that the document be provided by the end of the day on 11/17/2023. On 11/17/2023, another email was sent to the operation stating that documents had not yet been received and for them to be provided. On 11/20/2023, documents were provided by the operation.


raw_content: Records/Documentation was requested 2 times by an investigator and 1 time by a licensing supervisor. It was initially requested on the October 27th, and it was not sent until November 14th at approximately 10:51 PM.

Correction Narrative: Documentation was received.


summary: 748.1203(a) - Admission-Operation may only admit children and young adults who meet admission policy and whose needs can be met at the operation

raw_content: A child in care who was admitted to the operation despite being outside of the licensed age range.

Correction Narrative: The child is no longer at the operation.


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: It is found after the review of the incident report that the incident occurred on 08/08/23 and the child in care left the operation at 7:27pm. It was reported to licensing on 8/09/23 at 12:01pm.  This reporting to licensing is not in the required time frame.


summary: 748.1101(b)(4)(A)(vi) - Children's rights- To be free from being threatened with the loss of placement or shelter as punishment

raw_content: Multiple children in care reported staff threatening to send children to a "mental hospital" even when there were times where a child's behaviors did not warrant such hospitalization.

Correction Narrative: Training certificates were sent for Ms. Anita and Mrs. Octavia.


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

raw_content: Records were requested on 7/3, 8/2, 8/3, and 8/4. Partial records were received on 8/3. An inspection to the operation was conducted on 8/18 where 4 service plans were obtained; however incident reports being requested were not in the child's files. Licensing was informed that incident reports may have been scanned into the operation's electronic system. Those incident reports were requested to be sent to Licensing by end of the day on 8/18. The incident reports were never received.

Correction Narrative: The administrator has been informed on the importance of sending documentation in a timely matter. If there is a miscommunication with record requests, then she will communicate with Licensing the reason for the delay. She is delegating tasks with another employee to lessen her workload.


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

raw_content: Insulin was found unsecured in the refridgerator.


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

raw_content: This operation did not report the 1st Quarter (January-March) EBI numbers as required despite several reminders by the RCCR Inspector via email to the operation on 4/18/23, 5/1/23 and 5/2/23.


raw_content: At the time the case was called in, the operation had 5 girls in placement and was only licensed to take boys.  The operation now has a new permit allowing placement of both boys and girls.

Standard Number / Description: 748.1203(a) - Admission-Operation may only admit children and young adults who meet admission policy and whose needs can be met at the operation


facility_name: Unity Children's Home - Boys

summary: 748.121 - Abuse and neglect policy - You must develop policies on preventing, recognizing, and responding to abuse and neglect of children

raw_content: The operation did not include all the specific requirements per minumum standards.

Correction Narrative: Operation submitted updated policy to reflect requirements.


summary: 748.123(8) - Vaccine preventable policy - state disciplinary actions you may take against employee if failure to comply with policy.

raw_content: The policy did not state disciplinary actions they will take.

Correction Narrative: Operation submitted vaccine preventable disease updated policy to reflect disciplinary actions.


summary: 748.1101(b)(4)(A) - Children's rights-The right to be free from any harsh, cruel, unusual, unnecessary, demeaning, or humiliating treatment or punishment.

raw_content: 3 of 4 residents reported staff used profanity to or around children in care.

Correction Narrative: 3 of 3 residents stated that staff do not use profanity to or around children in care.


raw_content: One staff member who was employed from July 2020-January 2021 was working at the operation with access to children in care without submitting or receiving results of an initial background check.

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

Correction Narrative:
On 6-9-21 a written corrective action was received from agency program director Harriet Callion stating the following: A background was cleared on this staff but at the operation # 1594840. Unity Children's Home agency understand and acknowledges the importance of background checks and verification. There for, all staff background (new employees) will now be submitted under the Gils and Boys Facility license so that the Unity Children's home will remain in compliance with this Minimum Standard Rule. A remedy was provided in May 2021 and this staff ha been removed from the schedule since her maturity leave as of 1-4-21. I have attached a copy of the request from your record.
This staff member has not been working a the operation since 1-4-21.


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

raw_content: Two children in care made an outcry that a staff member has offered a bribe for them to fight other residents at the operation.

Correction Narrative: During the visit to the operation three children were interviewed and denied that this has continued to occur.


raw_content: One staff member who was observed working at the facility directly supervising children in care did not have a cleared initial background check.


facility_name: Empower Youth Homes LLC

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:
Staff did not report a child in care required medical care.
Staff should report incidents that require physician treatment to a child iin care.

Correction Narrative: Several attempts to call provider were made and emails requesting compliance plans were sent. Although compliance plan was not received and compliance could not be verified due to operation no longer operating no additional citation will be issued as the operation is no longer in operating status. Operation does not have children in care and no longer operates as a child placing agency. Should the operation want to come back into operating status an inspection will be required, and documentation will be requested.


raw_content: Staff instructed another child in care to go get the other child out of their room. This caused an altercation between the two children.

Correction Narrative: Several attempts to call provider were made and emails requesting complaince plans were sent. Although compliance plan was not received and complaince could not be verified due to operation no longer operating no additional citation will be issued as the operation is no longer in operating status. Operation does not have children in care and no longer operates as a child placing agency. Should the operation want to come back into operating status an inspection will be required, and documentation will be requested.


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

raw_content: Staff are not following the 1:1 supervision during waking for a child in care that requires 1:1 supervision.


summary: 748.4003(1)(A) - General requirements-When transporting a child the operation must ensure each driver is at least 21 years old

Correction Narrative:
A caregiver who is 18 years old that has a restriction C on their driver license has confirmed they have driven a youth in care on multiple occasions.

Interviews with the youth in care deteremined this to be in compliance.


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

Correction Narrative:
Multiple accounts indicate caregivers did not physically intervene to ensure the safety of a youth in care who was engaging in a physical altercation with another caregiver.

Interviews with the youth in care deteremined this to be in compliance.


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

Interviews with the youth in care deteremined this to be in compliance.


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

Correction Narrative:
A caregiver retaliated by hitting a youth in care during a physical altercation.

Interviews with the youth in care deteremined this to be in compliance.


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

raw_content: Two staff were observed completing administrative and other duties while being counted in ratio.

Category: Child/Caregiver Ratios

Correction Narrative: Corrected by enough staff observed in ratio at the operation during the follow up inspection.


summary: 748.3443(a)(4) - Food Preparation-Food items must be stored in a container that is protected from insects & rodents

raw_content: A pancake mix box was observed left open in the food storage area.


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

raw_content: One out of three employee files reviewed did not have the employment affidavit notarized.

Correction Narrative: A copy of the notarized affidavit was provided during the follow up inspection.


summary: 748.2301(a) - Disciplinary Measures-only a caregiver known to and knowledgeable of the child may discipline the child

raw_content: Children in care intervene and separate children during fights.

Correction Narrative: Corrected by interviews being conducted with youth in care.


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

raw_content: A caregiver told a child in care they would end up homeless, teased children in care about their past trauma, and antagonized children in care to prompt misbehavior/outburst.


summary: 748.1101(b)(4)(A)(vi) - Children's rights- To be free from being threatened with the loss of placement or shelter as punishment

raw_content: Children in care were told and reminded that they would lose their placement if they did not behave.


summary: 748.4083(b) - Vehicle and maintenance-Each vehicle used must be registered and have a current inspection sticker for the state in which it is registered

raw_content: The operation's vehicle inspection sticker expired 2/28/2025.

Correction Narrative: Corrected


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

raw_content: The thermometer in the large freezer is reading at 12 degrees and the thermometer in the refrigerator is not functioning properly.

Correction Narrative: An email was received from the operation's administrator indicating a new refrigerator was delivered to the operation to replace the old one. During investigation inspection #4044550, the new refrigerator was observed to still be cooling down. On March 4, 2025, pictures of the current temperatures of the freezer and refrigerator were received from the administrator.


summary: 748.751(b)(2) - Pre-Employment Screening-You must document the results of any contact with an applicant's previous employers in the personnel file.

raw_content: Two out of three employee files reviewed did not contain detailed documented information regarding the conversation or attempts made for employment history checks.


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

raw_content: Two of the children's service plans specify a supervision plan of one staff to three children due their high-risk behaviors. However, on the day of the incident, only one staff member was present to supervise four children.

Correction Narrative: An email was sent by the operation's administrator indicating she will ensure at least two direct care staff are scheduled per shift that will not be an administrative staff.


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

raw_content: The medication count was documented incorrectly on the med log for two medications.

Correction Narrative: Corrected.


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

raw_content: A child in care was not given their medication as prescribed.


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

Deficiency Narrative: The medication count was documented incorrectly on the med log for two medications.


summary: 748.303(b) - Serious Incident-Not required to report medically pertinent incident if not level of serious incident. Document same as a serious incident

raw_content: The incident documentation did not indicate the time of the incident. Incidents that do not rise to the level of a serious incident must be documented in the same manner as a serious incident.

Correction Narrative: A copy of the incident report with the time of incident added to the form was received.


summary: 748.683(2) - Caregiver Supervision-Provide oversight of caregivers to ensure that assigned duties are performed adequately

raw_content: The operation did not provide appropriate caregiver oversight when leaving a single employee that was male to provide supervision and conduct bed checks. The male staff was unable to enter child bedrooms, per operation procedure to not leave camera view, to physically see/check that children were in bed. As a result, a child eloped without a caregiver knowing.


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

raw_content: A caregiver did not provide the level of supervision for a child in care and was not aware a child was no longer present at the operation.


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

raw_content: Children were allowed to hear other children's private information during medical appointments.


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

raw_content: Three out of three employee files reviewed did not contain documentation of employment history checks for all previous employers in the previous five years.

Correction Narrative: A phone call was received from the operation's owner who stated she is the responsible party for hiring employees. After reviewing the Minimum Standard with the owner, she stated she was confused on the standard originally and will update their new hire form to include reference checks from previous employers as well so the operation will be in compliance moving forward.


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 left vehicle keys in common area where resident had access to them. Resident took vehicle keys and locked herself in the vehicle.


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 to be deficient as part of a DFPS investigation.

Correction Narrative:
On August 29, 2024, a review of the operation's online background check was completed. It indicated the employee involved in the investigation was inactivated on August 19, 2024.

On September 3, 2024 youth in care were interviewed at school. It was confirmed the employee involved in the investigation has not been at the operation and no physical discipline is being utilized.


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

raw_content: A caregiver intentionally pushed and hit a youth in care during an altercation.


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

raw_content: It was observed that four beds did not have mattress cover or protector. It was also noted that there were no sheets.


raw_content: Multiple children in care mention staff threatening loss of placement.

Standard Number / Description: 748.1101(b)(4)(A)(vi) - Children's rights- To be free from being threatened with the loss of placement or shelter as punishment

Correction Narrative: Follow up inspection #4011760 was completed at the operation in which youth in care and staff were interviewed. There were no concerns expressed regarding staff threatening the youth in care.


summary: 748.1337(a) - Initial Service Plan-Base on needs identified in admission assessment; justify delay in addressing needs if service planning team prioritizes goals

raw_content: The service plans reviewed all contained the same information verbatim for the supervision needs of each child.


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

raw_content: The operation failed to adjust a childs medication as recommended by the health-care professional upon discharge from the hospital.

Correction Narrative:
Email received from the operation on 07/19/2024, stating:

When a child is discharged from the hospital, the hospital completes the discharge paperwork WITH the staff picking the child up.
As such, we have the Treatment Director pick the child up for that reason.
This is what was done, and this is what we continue to do.

We had a meeting on June 11, 2024, to discuss reviewing discharge paperwork immediately.


raw_content: It was determined that staff members do not use prudent judgement when responding to children when they are upset.


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: Three out of three medication logs reviewed were missing documentation to show medications were administered.


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

raw_content:
During the walkthrough,  there were wood boards and loose  bricks laying around in the backyard. Also, in one of the living rooms there was a pack of screws observed laying out next to the firplace.

Attempted to follow-up and the physical site was still not  in compliance.


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

raw_content: Staff are using profane language around the children in care.


raw_content: During the walkthrough,  there were wood boards and loose  bricks laying around in the backyard. Also, in one of the living rooms there was a pack of screws observed laying out next to the firplace.

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


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

raw_content: It was found during the investigation by an investigator that there were multiple children with 1 or 2 pills missing; medication errors were not documented.


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

raw_content: Two out of four youth files reviewed contained service plans that were missing information.

Correction Narrative: An email was received from the operation's administrator that included an updated copy of the documents with missing information to show they have been corrected.


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

raw_content: Two out of two medication records reviewed did not have documentation completed  for medications that were administered daily over a period of 4 days.

Correction Narrative: An email was received from the operation's administrator that included a copy the corrected medication logs for verification of them being corrected.


summary: 748.125(d)(4)(A) - Suicide Screening- A screening tool must be administered at admission for each child 10 years of age or older.

raw_content: One out of four youth files reviewed did not contain a suicide screening from admission.

Correction Narrative: An email was received from the operation's administrator that included a copy of the missing suicide screening.


summary: 748.3443(a)(4) - Food Preparation-Food items must be stored in a container that is protected from insects & rodents

raw_content: Open chips and cereal was found open in the pantry and were not stored in a closed container after being opened in the original bag.

Correction Narrative: During the inspection, the operation ordered pantry containers online to be delivered the next day to keep opened food inside. A screenshot of the order confirmation was provided for verification.


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 operations, spoiled milk was found inside of the refrigerator {expiration date: Oct. 17, 2023}.


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

raw_content: During the inspection, it was observed one staff completing administrative duties while being the only staff counted in ratio to supervise the youth in care for more than 30 minutes.

Correction Narrative:
A corrective action plan was received via email from the operation's administrator indicating the following: Director will not be counted in staff to client ratio after 7/30/2023.
-Director has been removed from Staff schedule as a Youth Care Worker. A copy of a staff schedule was provided during the inspection on 8.22.23.


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

raw_content: One out of the four youth files reviewed did not contain the child's signature on their child's rights document.

Category: Children's Rights

Correction Narrative:
A corrective action plan was received via email from the operation's administrator indicating the following: Identified files will be noted.
-Director will conduct post admission audits and continuous audits to ensure all signatures and necessary forms are captured.


summary: 748.1101(b)(5)(B) - Child rights-participate in service plan within child's ability to manage info and have copy of plan Child 14 yo or older right to review/sign plan

raw_content: One out of four youth files reviewed did not contain the youth's signature on their service plan.

Correction Narrative:
A corrective action plan was received via email from the operation's administrator indicating the following: Identified files will be noted and corrected.
-Director will conduct post admission audits and continuous audits to ensure all signatures are captured appropriately. Updated documentation was provided.


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

raw_content: One out of four youth files reviewed did not include a preliminary service plan.

Correction Narrative:
A corrective action plan was received via email from the operation's administrator indicating the following: Identified file will be noted and corrected. A copy of the 72-hour service plan was provided.
-Director will conduct post admission audits to ensure all signatures and forms are captured appropriately.


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

raw_content: Several living insects were observed inside and outside of the operation.

Correction Narrative: A corrective action plan was received via email from the operation's administrator indicating the following: Pest control services were called for immediate application in and out of the operation.  Pest control services will continue to be scheduled for monthly visits to ensure insects are limited in the operation. Work Order submitted on 7/31/2023. A copy of the receipt for payment of pest control was obtained as well.


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: Two out of four serious incident reports reviewed were not reported to Licensing.

Correction Narrative:
A corrective action plan was received via email from the operation's administrator indicating the following: Identified reports will be used as training tools to ensure all staff are knowledgeable in what is considered reportable by licensing standards.
-Director will ensure that all reports are reviewed and properly processed by either reporting to licensing or submitting to TPG data base.


raw_content: During the walkthrough, the operation's grounds were observed to have several hazardous objects such as loose bricks and wood planks as well as a small metal ladder. There was also a fallen tree branch in the backyard still somewhat connected to the tree.

Correction Narrative: Corrected


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

raw_content: Several beds in the operation were missing all required bedding components.


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

raw_content: During the walkthrough, a thermometer was not observed in the refrigerator.


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

raw_content: Seven out of fifteen beds did not include all required bedding components.

Correction Narrative: Corrected. An admin review has been submitted.


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

raw_content: One out of two employee files reviewed did not indicate the date of employment, did not include a job description, acknowledgement of reporting abuse/neglect, verification of age requirements, affidavit for employment, and a job description.

Correction Narrative: Administrator states there has been an administrative review submitted due to the operation not currently having active employees.


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

raw_content: Cleaning supplies were observed in an area accessible to youth in care.


summary: 748.2553(2)(E) - EBI Release-Child released from personal restraint when maximum time allowed for personal restraint is reached

raw_content: Policy doesn't indicate child will be released from EBI after meeting timeframe per Minimum Standards.

Correction Narrative: An email was received from the operation's administrator, Alyssa Phillips, which included a copy of the operation's updated policy.


summary: 748.2755(a)(1) - Simultaneous Interventions-May use emergency medication with mechanical restraint only if allowed by operation's policies

raw_content: There was not a policy that mention simultaneous interventions and the use of mechanical restraints/emergency medication.


summary: 748.3101(1) - Fire Inspection-Must have fire inspection before initial permit issued

raw_content: Operation has not had a fire inspection completed yet.

Correction Narrative:
An email was received on February 28, 2023 from the operation's owner indicating the fire marshal has scheduled the operation's fire inspection for March 10, 2023; therefore, an extension will be granted.

An email was received on March 10, 2023 from the operation's owner indicating the fire inspection was completed. An attachment was included of the passed fire inspection.


summary: 748.2753(a)(1) - Simultaneous Interventions-May use emergency medication with personal restraint or seclusion only if allowed by operation's policies

raw_content: The policy does not mention Simultaneous Intervention.


summary: 748.2751(a)(1) - Successive Interventions-Caregiver may successively use emergency behavior interventions on a child only if allowed by operation's policies

raw_content: The policy does not include successive use of EBI.

Category: Emergency Behavior Intervention

Correction Narrative: An email was received from the operation's owner, Alyssa Phillips, that included an updated version of the operation's policies.


summary: 748.393(b)(2) - Active child record-Includes known allergies and chronic conditions or

raw_content: The child file needs a place to document allergies.

Correction Narrative: A copy of the allergies/medical conditions was placed on the exterior of the mock child file.


Standard Number / Description: 748.2755(a)(1) - Simultaneous Interventions-May use emergency medication with mechanical restraint only if allowed by operation's policies

Deficiency Narrative: There was not a policy that mention simultaneous interventions and the use of mechanical restraints/emergency medication.


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:
Log needs to include:
(1)Childs full name
(2)Prescribing health-care professionals name, if applicable; [Medium]
(3)Reason medication was prescribed, for prescription medication [Medium];
(4)Medication name, strength, and dosage [Medium-High];
(5)Date (day, month, and year) and time the medication was administered [Medium High];
(6)Name and signature of the person who administered the medication [Medium];
(7)Childs refusal to accept medication, if applicable [Medium]; and
(8)Reasons for administering the medication, including the specific symptoms,
condition, and/or injuries of the child that you are treating, only for [Medium-High]:
(A) PRN psychotropic medications; and
(B) Nonprescription medications and supplements for children under five years
old.
(d)Unless you operate on a cottage home model, you must count each medication daily


summary: 748.105(9) - Personnel Policies - Drug testing policy meets or exceeds DFPS' model policy in 745.4151

raw_content: The policy does not include information about staff needing a drug test upon being hired.


summary: 748.105(5) - Personnel Policies - Develop written policies on whether caregivers may take children away for  day/overnight visits, ensure policy meets requirements

raw_content: The policy does not mention if staff are allowed to take children away for day/overnight visits.


summary: 748.121(1) - Abuse and neglect policy - required annual training for employees

raw_content: The policy does not list required trainings for the employees.


summary: 748.3001(b) - Sanitation Inspection-Each inspection must meet regulations of the local health department ordinances

raw_content: Operation needs a sanitation inspection.

Correction Narrative: An email was received from the operation's owner, Alyssa Phillips, that included a completed DFPS Form 4004 for an Environmental Health Checklist. A separate email was also sent showing emails between the owner and the county's health department regarding the operation not being eligible for a health inspection at the time due to not planning to prepare meals at the operation.


summary: 748.1439(b)(1) - Discharge Documentation-Discharge summary provided to next placement or caregiver within 15 days of discharge

raw_content: Missing a form to provide all of the information to the next placement.


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

raw_content:
The admission assessment is missing a spot for the identification of any risk factors or warning signs of suicide. The safety plan staff and caregivers will implement related to the risk factors and warning signs.
Also missing a spot for the results of the suicide screening at admission, if required.