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

raw_content: A child in care was restrained because she threw a ball that hit an employee on the leg.

Correction Narrative: 1.	Upon discovery of the video footage of in the incident, Ms. Ava was suspended from 11/19/21-11/24/21. A plan was put in place where she agreed to refrain from acting in retaliation, using improper methods to gain compliance, use proper SAMA methods, and attend a mandatory training on behavior management and crisis intervention. The suspension and disciplinary action are both attached for your review. The training will be held this Friday, January 7, 2022.


state: TX

facility_name: Girls Haven

summary: 748.2463(2) - Emergency Behavior Intervention-Never used as retribution or retaliation

raw_content: A child in care was placed in a restraint due to staff retaliation.

Category: Individual Standards Evaluated

Standard Risk Level: Medium High

Corrected at Inspection: No


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

raw_content:
During the inspection, it was found that the Development Public Relation Coordinator did not have a background check submitted or cleared prior to being allowed to be present at the operation. In order to assure timely completion of background checks, it is recommended
that the operation submit background checks prior to allowing employees to be present at the facility.

Standard Risk Level: High

Corrected at Inspection: Yes


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

raw_content: One child's initial service plan does not document history of high risk behaviors nor plans to address the high risk behavior.

Category: Admission, Service Planning, Discharge

Correction Narrative: 7/19/21-Operation has scheduled a service plan review meeting for 7/27/21, to update the service plan regarding history of high risk behaviors and plans to address high risk behaviors.


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

raw_content: One service plan review does not document plans to address risk of runaway for a child who has a history of running away.

Standard Risk Level: Medium Low

Correction Narrative: 7/19/21-Operation has scheduled a service plan review meeting for 7/27/21, to update the service plan to address high risk behaviors.


summary: 748.1501(a)(4) - Dental care-Children in care must receive dental care as needed for ongoing maintenance of dental health

raw_content: One child did not have a 6 month dental exam.

Category: Child Care

Correction Narrative: 7/19/21-Operation provided corrective plan. The child's dental appointment has been scheduled for 7/23/21.


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

raw_content: One child did not have a TB screening until 3 months after placement.

Standard Risk Level: Medium

Correction Narrative: Operation provided copy of the completed TB screening. Operation's plan to address is to ensure required dates are tracked and appointments scheduled in advance.


summary: 748.3301(a) - Physical Site-Buildings must be structurally sound, clean, and in good repair. Paints must be lead-free

raw_content: Two bathrooms at the facility (R-4 and A-19) have visible water damage on the ceiling tiles.

Category: Physical Site

Correction Narrative: The operation submitted an updated plan regarding HM Plan Task #5 that was accepted and approved by the HM Team effective 06-21-21.


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

raw_content: During the inspection, 1 child did not receive prescribed medication as prescribed. The child was out of medication on 04-25-21 and was provided the nonprescription brand, until the prescription was filled on 04-30-21.


facility_name: Paradigm Treatment Texas

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 during the walk through  multiple beds did not have mattress covers on mattresses, that were not waterproof.

Correction Narrative: On 02/03, Inspector received compliance photos which reflected the operation had put mattress covers on the bed.


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: Three out of four vehicles used to transport children had expired inspection stickers. Two vehicle's inspection stickers expired in May 2024 and the third expired in September 2024.

Correction Narrative: Administrator, Mr. Jeffery Edmonds, sent pictures of all three vehicles which included their license plate numbers. The pictures reflected that all three vehicles had up to date inspection stickers.


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

raw_content: Video footage obtained revealed two children were in a bathroom for approximately 12 minutes and engaged in inappropriate activity.

Correction Narrative: Two staff were interviewed and it was verified that a supervision training was completed. The staff discussed supervision, ratio, and restroom protocol. There were not any concerns noted. Two children were interviewed and staff supervision was discussed with no concerns noted. Documentation was reviewed which confirmed a supervision training was completed on 10/24/2024.


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

raw_content: Video footage at school revealed there were there were initially 4 staff with 18 kids however 1 staff member and 1 child left leaving the operation out of ratio at 17 kids to 3 staff.


summary: 748.1209(b)(8) - Child Orientation-Include policies on the religious program and practices

raw_content: Two out of two child files reviewed reflected it did not include operation policies on their religious program and practices as well as gifts.

Standard Risk Level: Low

Correction Narrative: Operation provided a copy of child rights which will include notification of Paradigms policies on religious program and practices for clients and parents' signature. The copy will also be placed in the client's workbook for review at any time and it will be reviewed during client's orientation at admission.


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

raw_content: Observation during walkthrough of operation revealed fire extinguishers in the three homes and the school to have been last inspected December 2022.

Correction Narrative: Operation provided documentation of company inspecting fire extinguishers on 04/17/2024.  There will be fire extinguisher monthly audits added to their Safety Protocol monthly walk through and auditing updates. The Administrator, Mr. Jeff Edmonds, will be listed as the responsible party for all Safety Protocol audits.


summary: 748.911(c)(1) - Each caregiver must be certified in first aid within 90 days of employment.

raw_content: Staff file reviewed indicated CPR/First Aid was completed after 90 days of employment and had access to children in care.

Category: Training and Professional Development

Correction Narrative: On 9/11/23 an email was received stating that, "All current employee files have been updated to meet this minimum standard. It has also been implemented in Human Resources policy that CPR certification be assigned or documented on the employee's first day of employment with Paradigm Treatment Centers."


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

raw_content: Child files reviewed did not indicate any known contraindications to the use of restraints during their pre or post admission documentation.


raw_content: Child in care placed at the operation for 55 days with no TB test.

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

Correction Narrative: On 9/11/23 an email was received stating that, "Admission assessment and nurse screening assessment has been updated to provide tuberculosis (TB) screening and/or provide a TB skin test at admissions. The EHR (electronic health record) of our agency has also been updated to include a medical check list for all new admissions to ensure a TB screening has been provided to each client.


summary: 748.1217(b)(14) - Admission Assessment-At admission, must include parent's expectations for placement, duration of placement, & family involvement

raw_content: Operation does not have goals or expectations from the parent in their current admission procedure/documentation.


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

raw_content: Placement agreement currently in place did not indicate the reason and length of time when child is placed at the operation.


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

raw_content: Two child records reviewed were missing items in children's rights.

Correction Narrative: The operation provided the updated child rights form and reflected all of the necessary requirements for that section.


summary: 748.3603(j) - Doors from operation leading to pool area must have lock that can only be opened by adult unless lock violates fire code and documentation is on file

raw_content: Multiple doors leading to the swimming pool do not have a lock.

Correction Narrative:
On 6/12/23 email was sent with photos of doors leading to pool areas with a padlock and uploaded into SharePoint.
On 7/14/23 An in-person inspection was conducted and doors leading to the pool area were all inspected to have padlocks or custom locks in place.


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: When requesting drug tests not all staff was drug tested. HR is allowing staff to set up dates to get drug tested by today and get drug tested by the end of June.

Correction Narrative:
On 6/29/23 an email was sent with a list of all current staff totaling to 36 current staff, all testing negative, with 1 pending result and 2 who have yet conducted the screening due to medical leave and will do so upon arriving back to the facility as per policy.
7/14/23 An in-person inspection was conducted and facility had all current staff working at the facility drug tested and with a negative on their finding result.


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

raw_content: 2 out of 2 documents reviewed showed medications for clients were taken past the hour scheduled to be taken.

Category: Medication

Correction Narrative:
On 7/3/23 email was sent stating that their policy will now require children to wake up at regular time even on the weekends to take their medication on time. Schedule changes with staff have been made to comply with minimum standard.
7/14/23 An in-person inspection was conducted and electronic medication log of a pervious resident and current resident were reviewed to verify that within the last 2 weeks they have been taking their medication within the one hour of preparation.


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 staff members were made unaware of 2 residents leaving the home and walking around the facility during their bedtime for about an hour.

Correction Narrative:
On 7/10/23 an email was sent stating that training policy will be updated to include that all doors are secure, and alarms are set, and in working order prior to bedtime. Training policy will be included to reflect all staff are trained in securing all doors and monitoring any alarm system to always ensure client safety.

On 7/31/23 4 residents were interviewed and reviewed ratio, general supervision, procedures for when someone runs away, and first aid. 2 staff were interviewed and updated licensing about all doors being locked except emergency exits, supervision with children, and their procedures for when a child elopes.


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

raw_content: 1 out of 2 records reviewed contained no notarized affidavit.

Category: Reports and Record Keeping


summary: 748.311(10) - Serious Incident Documentation-Includes resolution of the incident

raw_content: 4 out of 4 incident reports reviewed did not contain a resolution section.


summary: 748.153(3)(B) - Notification - New controlling person

raw_content: New director not added into controlling persons withing 24hrs of DOH.

Category: Organization and Administration


summary: 748.311(11) - Serious Incident Documentation-Must include an update regarding the unauthorized absence and the childs return.

raw_content: 4 out of 4 records reviewed contained no section for addtional information for child runaways.


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

raw_content: The operation did not include the address, telephone number, or relationship of the person to whom the child was discharged to on the discharge summary.

Correction Narrative: The operation has updated their electronic health record to request this information specifically name, relationship to individual, address and telephone number.


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

raw_content: 4 out of 4 records did not have the immunization record documented in the resident's record.

Correction Narrative:
On 3/21/23 Ms. Ware sent an email with the following:

1.	Our Admissions Team will be sending parents the attached assessment to complete prior to admissions (stored in EMR)
a.	This will identify neonatal history and dates of immunizations, dental, hearing, vision and medical exams
2.	Our Admissions Team will then be reviewing, collecting, & uploading the following documents (documentation for immunizations, dental, hearing, vision and medical exams) that align with the attached
3.	If a client does not have said exams prior to intake, our Admissions Team will inform our Head Nurse, who will make plans with the families to complete within first week of admissions

A test document was also uploaded to SharePoint showing all medical documentation.


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

raw_content: 4 out of 4 records did not have medical, and dental records documented in the child's record.

Correction Narrative:
On 3/21/23 Ms. Ware sent an email with the following:

1.	Our Admissions Team will be sending parents the attached assessment to complete prior to admissions (stored in EMR)
a.	This will identify neonatal history and dates of immunizations, dental, hearing, vision and medical exams
2.	Our Admissions Team will then be reviewing, collecting, & uploading the following documents (documentation for immunizations, dental, hearing, vision and medical exams) that align with the attached
3.	If a client does not have said exams prior to intake, our Admissions Team will inform our Head Nurse, who will make plans with the families to complete within first week of admissions.

A test document was also uploaded to SharePoint showing all medical documentation.


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

raw_content: 4 out of 4 records were missing the vision and hearing exam in the children's record's.


summary: 748.1217(c)(3) - Admission Assessment-Prior to initial service plan, add child's birth and neonatal history

raw_content: 4 out of 4 records did not contain the neonatal history recorded in the resident's chart.


raw_content: The operation did not include the name or information of the person the child was discharged to on the discharge summary.

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

Correction Narrative: The operation provided an updated copy of their discharge summary template including a section to list who the client will be discharged to and to include the name and contact information of this person.


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

raw_content: Four employees do not have cleared fingerprint results from the CBCU and have began employment.  Three of four of the employees work directly with the children. One of four of the staff's background checks is showing as inactive in CLASS.

Correction Narrative: Email received on 01/03/23 stating that the (3) staff in question have been cleared. From here on out all staff will be required to complete Background checks before starting employment.


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

raw_content: Several fire extinguishers were observed to have low pressure or in the red, no documentation of service date, and one fire extinguisher was last serviced in October 2018,

Category: Safety and Emergency Practices

Correction Narrative: On 12/19/22, an email was received from the operation with several photos of fire extinguishers indicating the fire extinguishers were inspected in December 2022 and fire extinguisher pressure for the fire extinguishers are in green/does not need to be recharged. Tags indicate the fire extinguishers are new. Photos uploaded into SharePoint digital storage.


summary: 748.2003(b)(11) - Administration of prescription medication-only the child for whom the prescription medication was prescribed may use the medication

raw_content:
During the investigation, it was found that a direct care staff administered a prescription medication to a teenager in care that was requested by the child, but this medication was not supposed to be administered to this child because there was no health care professional order for the prescription medication. There were no reported injuries, adverse actions or drug reactions for the child that would have caused harm.

It was also found that children in care have been administered two different as needed prescription medications from the same prescription bottle prescribed to the operation as a whole.

Correction Narrative: The operation reported they have consulted with their contracted psychiatrist that all prescribed meds will only be given to the child that is prescribed that individual medication and labeled accordingly for specific child. This standard will be complied by 2/03/2023. The staff involved in the incident who gave unprescribed medication has gone through re-training on med pass as of 1/15/2023 and will continue to receive training.


raw_content:
During the investigation, it was found that one (1) staff who was reported to be an employee of the operation has a pending fingerprint background check but has been working at the operation on an as needed basis as a nurse.

Another staff who was reported to be a personal trainer on campus for the children in care who is considered a volunteer of the operation did not have a 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 2/1/23, in speaking with the operation by phone the Administrator reported they will make sure to run the background check for the personal trainer and moving forward they will ensure any other background checks are properly run. The Administrator reported the "as needed" Nurse will not be working until cleared. The Administrator and Executive Director will ensure compliance.

Additionally, on 2/6/23, the operation reported through email that the nurse is waiting on fingerprints as they were closed through the winter storm last week. This Nurse will not work until the background check has completely cleared and they reported the personal trainer background check has been submitted and they are awaiting results.

As of 2/7/23, the PRN Nurse's fingerprints cleared and on 1/30/23, the contract Personal Trainer's background check was submitted and Eligible as of 2/24/23.


summary: 748.1345(1)(B) - Initial Service Plan-For ED and ASD treatment services, PLSP must review identified needs and plan for treatment based on child's diagnoses

raw_content: The operation continued to care for a teenager in care who has history of trauma related to human trafficking as documented in the child's Biopsychosocial Assessment, however the operation doesn't provide this service.

Correction Narrative: The operation has determined that if information comes out before admission that a child has been found to be outside of their licensing requirements, they will look for a different placement for the child or seek assistance with an outside contract service to meet the need of the child and inform DFPS agency. If they find out information after admission of the child, they will seek assistance to meet the needs of child and will inform DFPS agency for compliance. They reported they will comply with this standard as of 2/03/2023. On 2/1/23, it was also discussed by phone with the operation Administrator and Executive Director that in certain situations where the operation is not able to meet a standard, then they may submit a variance if needed temporarily and licensing would either approve or deny it based on the child's best interest and other requirements.


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: One staff who has a Provisional background check with conditions was reported to have been working at the operation with direct access to children in care and administering medications to children in care, this staff was working at the operation on 1/27/23.

Correction Narrative:
On 2/1/23, in speaking with the operation by phone the Administrator reported they will make sure moving forward they will ensure background checks are properly run. The Administrator reported for the direct care staff with the Provisional background check they will ensure conditions are followed and if any other staff are hired w/ provisional background checks, then they will make sure they follow all conditions. The Administrator and Executive Director will ensure compliance.

Additionally, on 2/6/23, the operation reported the direct care staff has sent in documents from Colorado to clear their background check and the person within the background company stated this will clear the provision and will enter it ASAP but that they were swamped since the closure last week due to severe weather.

As of 2/7/23, the direct care staff's provisional background check cleared and is now without any provisions.


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

raw_content: A child in care was able to gain access to the operation's medication storage area and obtain another child's prescription medication without any staff witnessing the incident.


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

raw_content: A child in care was able to obtain another child's prescription medication due to the medication storage area being left open and unlocked and unattended by staff.


summary: 748.363(4) - Personnel records-Include evidence of valid professional licensures, certifications, or registrations required for the position

raw_content: Copy of Clinical Social Worker License not in personnel record.

Correction Narrative: On 10/5/22 email was received with proof of employee's Clinical Social Worker license.


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

raw_content: The 2 doors leading to the water heater were not locked. 1 out of 2 doors that contain electrical wires were not locked.

Correction Narrative: Email received on 10/5/22 from operation with a picture showing a lock was placed on door so that children could not access the water heater and electrical wires.


summary: 748.505(b)(2) - Minimum qualifications for employees-Record of a TB screening showing the employee is free of contagious TB as provided in 749.1583

raw_content: 1 out of 2 staff records reviewed that will be working with residents directly did not have a copy of their TB results.

Category: Personnel

Correction Narrative: Email received on 10/06/22 with documentation showing proof of the 1 out of 2 staff members that was missing a copy of their TB results.


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

raw_content: Fire Inspection was not provided.

Deficiency Narrative: Fire Inspection was not provided.

Correction Narrative: On 10/25/22 email was received from the fire department a letter confirming that the certificates that the facilities have are to be used as their formal PASS for the fire inspection. Uploaded into digital storage.


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

raw_content: Sanitation Inspection was not provided.

Deficiency Narrative: Sanitation Inspection was not provided.

Correction Narrative: On 10/20/22 an email was sent out with the sanitation inspection stating that it PASSED. Uploaded document into digital storage.


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

raw_content: Bedroom facing the pool has a metal structure that can be hazardous for a child if they fall over the balcony.

Correction Narrative: Email was received on 10/5/22 from operation with 2 photos showing that the metal structure by the balcony was removed.


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

raw_content: 1 out of 4 staff records reviewed was missing their affidavit in their file.

Correction Narrative: Email received on 10/5/22 with proof of completed employee's affidavit.


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

raw_content: Three mattresses were missing the cover.


facility_name: Phoenix Residential Investment Group LLC

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

raw_content: During the walk through, it was observed that the administration of medication was either blank or missing information for the past couple of days for multiple children.

Correction Narrative: The operation sent an email to RCCR staff stating we corrected the medical log same day you were out to visit, provided additional training to the staff, and came up with a plan to ensure this will not happen again. The plan is that the following staff will come in and check the medication within 2 hours to ensure the medication log is signed. The corrected medication log was obtained and uploaded to the document library.


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

raw_content: After reviewing an employees file, there was critical documentation missing.

Correction Narrative: The operation provided the staff members training via-email.


facility_name: JM Home Care Services, LLC

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 inspection, there were multiple cooked food items in Tupperware containers, which were not labeled with the cooked date nor the expiration date. There was also an expired peanut butter and almond butter in the pantry.

Correction Narrative:
The following corrective plan was provided by the operation:

Corrective Action Steps
1.	Immediate Action
o	All unsafe or improperly stored food and beverages were immediately discarded.
o	Kitchen and food storage areas were cleaned, sanitized, labeled and reorganized to meet health and safety standards.
o	All individually packaged food items were labeled with expiration dates or collected into Ziplock bags with expiration dates.
2.	Staff Training
o	Within 7 days, all staff responsible for food handling will receive refresher training on:
	Safe food storage (temperature requirements, sealed containers, expiration checks).
	Proper food preparation (handwashing, avoiding cross-contamination, cooking temperatures).
	Safe serving practices (sanitary utensils, gloves, preventing foodborne illness).
o	All new staff will complete food safety training during pre-service orientation.
3.	Monitoring & Compliance
o	Kitchen inspections will be conducted daily by designated staff using a Food Safety Checklist.
o	The Administrator or Supervisor will conduct a weekly audit of kitchen and storage areas, with findings documented.
o	Any non-compliance will result in immediate correction and retraining.
4.	Documentation
o	A temperature check will be completed for refrigerators and freezers, recorded twice daily. Staff will escalate any safety concerns to the Administrator to document.
o	A food discard log will be used to record expired or unsafe items removed from storage.
o	Training logs, inspection forms, and audits will be maintained for 2 years for licensing review.
Prevention of Future Deficiencies
By strengthening food safety training, revising policies, and establishing daily and weekly monitoring systems, the facility will ensure all food and beverages are consistently safe, sanitary, and compliant with DFPS Standard 748.3441(a).


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

raw_content: During the inspection, it was observed that the psychotropic medication cabinet was not double locked. It was corrected at inspection due to the staff locking the medication cabinet. The over-the-counter medications are in the same room, but they are unlocked in a cabinet.


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

raw_content: In the review of background checks, there were multiple active peoples and their roles are unknown at the operation.

Correction Narrative:
Corrective Action Steps
1.	Immediate Action (Effective Immediately)
o	All inactive staff (resigned, terminated, or no longer providing services) will be identified and reviewed.
o	Any currently inactive staff in the system will be deactivated within 24 hours of this plan submission.
2.	Ongoing Process for Deactivation
o	Administrator will ensure that all staff separations are reported within 24 hours of notice.
o	The Administrator (or designee) will update the DFPS Child Care Licensing Background Check system to deactivate inactive staff within 7 calendar days of separation.
3.	Tracking & Documentation
o	A Staff Separation Log will be created, listing the employee name, last date worked, date of notification, and date of deactivation in the system.
o	The Administrator will maintain this log for 2 years for auditing and compliance review.
4.	Training
o	All administrative staff responsible for background check compliance will be trained on DFPS standards 745.621(a)(2) and 745.651(1).
o	Training will include:
	How to deactivate staff in the system.
	Timeframe requirements (within 7 days).
	Documentation procedures.
5.	Monitoring & Oversight
o	The Administrator will conduct a monthly audit of staff records and background check status.
o	Any discrepancies will be corrected immediately, and corrective notes will be added to the Staff Separation Log.
o	A quarterly review will be conducted with leadership to ensure ongoing compliance.
Person(s) Responsible
	Administrator/Director  Responsible for compliance, oversight, and reporting.
	Human Resources/Designee  Responsible for logging staff separations and initiating deactivation requests.
Completion Timeline
	Immediate corrective actions completed: Within 24 hours of plan submission.
	Full compliance with 7-day deactivation process: Ongoing, effective immediately.
Prevention of Future Deficiencies
By implementing the above process, staff records will remain accurate, background checks will be properly maintained, and inactive staff will be deactivated within 7 days, ensuring compliance with DFPS minimum standards.


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

raw_content: During the review of background checks, a staff who never started working is still active on the operation's people list, and it is past the 7 day requirement.


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

raw_content: 5 out of 5 children interviewed stated that they have been to the owner's home on more than one occasion. Two legal guardians gave permission, while one was not asked for permission, and another was unaware of the visits.

Correction Narrative:
The operation provided the following corrective plan:

Standard: HHS Minimum Standard §748.507(1)  Employee General Responsibilities
Requirement: Employees must demonstrate competency, prudent judgment, and self-control in the presence of children and when performing assigned tasks.
________________________________________
Issue Identified
Employee(s) failed to follow appropriate procedures by:
	Bringing residents to their personal home,
	Not securing prior approval from all of the legal parents/caseworkers for outings, and
	Failing to follow operation policies.
This resulted in a violation of HHS Standard 748.507(1).
________________________________________
Corrective Actions
1. Immediate Action
	The employee(s) involved has been counseled and reminded of policy prohibiting taking residents to personal homes.
	All outings for residents are suspended until written caseworker or legal guardian approval is confirmed and documented.
	Staffing schedules were reviewed to ensure adult-to-resident ratios are met at all times, including transportation and offsite activities.
	New policy was written to provide guidance on taking residents to personal homes pending licensing approval.
________________________________________
2. Preventive Measures
	Policy Reinforcement: All staff have received notice and refresher training on HHS Standard 748.507(1) and agency policy regarding outings and supervision.
	Approval Protocol: The supervisor or the resident must obtain all details for any special individual outings or individual/group residential visits outside the operation. The outing must be approved by the child's caseworker/legal guardian at least 72 hours in advance, noted and received by the supervisor.
	Transportation Restriction: Employees are strictly prohibited from transporting residents to personal residences under any circumstances until the new policy is approved by licensing.
	Ratio Verification: Supervisors must verify proper staff-to-resident ratios are scheduled and maintained prior to any outing.
________________________________________
3. Training
	All staff will complete a mandatory training session on:
o	Professional boundaries,
o	HHS Standard 748.507(1) expectations,
o	Outing approval procedures, and
o	Supervision and ratio compliance.
	Training was completed September 11, 2025 for this corrective action plan task.
________________________________________
4. Monitoring & Accountability
	Supervisors will review and approve all individual or non-group outings in writing with child's caseworker/legal guardian.
	Random audits will be conducted monthly to verify documentation of approvals and ratio compliance.
	Employee performance evaluations will include adherence to HHS Standard 748.507(1).
	Any future violations will result in progressive disciplinary action up to termination.
________________________________________
Responsible Party
	Program Director  Ensures implementation of CAP and monitoring.
	Supervisors  Verify outing approvals and ratios.
	All Staff  Comply with HHS standards and agency policy.
________________________________________
Completion Date
All corrective actions will be implemented and documented within 30 days of this plan.


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

raw_content: Child's service plan addressed a high-risk behavior for suicide and operation did not follow the plan that was implemented to ensure that sharp items, including razors, were distributed only by staff and collected immediately after use.

Correction Narrative: An unannounced follow up inspection was completed on 8/5/25. Staff reported and it was observed during walkthrough that closets are locked, and sharp objects are kept in closets that locked. A log was created starting 7/25/25   named sharp object signing sheet to keep track of sharp objects in the home.


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

raw_content: Child in care was found to be high risk for suicide following a risk assessment and a mental health professional was not contacted or notified.


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

raw_content: Child in care was not adequately supervised after exhibiting dangerous self-harming behaviors which resulted in child engaging in additional self-harming behaviors.

Correction Narrative: An unannounced follow up inspection was completed on 8/5/25. Staff reported the children are not left alone, and there are 2 staff present at all times. They stated they have 1 night staff present at nighttime increased to 2 staff. They reported they review supervision based on a list of children and the level of supervision needed.  Children were interviewed during inspection and reported not having any protocol or people talk to them about suicide or high-risk behaviors. Sharp objects were observed to be locked, and a log is being completed for their use.


raw_content: Child had access to staffs personal keys and drove off in staffs vehicle.

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: Staff involved was placed on corrective action and provided with additional training. Operation held a meeting with all staff on 5/12/25 to discuss reinforcing operation policies to maintain a safe and professional environment for children in care.


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

raw_content: The operation provided conflicting information regarding the administrator's work schedule.  Additionally, information provided indicates that the administrator isn't adhering to a full-time schedule.

Correction Narrative:
The operation submitted the following response:
Effective immediately, the following steps will be implemented to ensure compliance with the standard:

1. The LCCA will adhere to a written weekly schedule reflecting full-time hours (minimum 30 hours per week), which includes on-site presence for monitoring, oversight, and administrative duties.

2. The LCCA will sign in and out daily using the designated LCCA Sign-In Log located in the administrative office. This log will record:
   - Date
   - Time in and out
   - Initials
   - Any relevant notes for the day

3. The sign-in log will be maintained in a secure binder and will be readily available to any Licensing representative upon request.

4. The Executive Director will review the log weekly to ensure accuracy and completion. Any inconsistencies will be addressed promptly with corrective steps.

5. This process will remain in effect continuously and will be reviewed quarterly as part of internal compliance audits.

Person Responsible:
Executive Director
CEO
Child-Care Administrator


raw_content: Multiple records were observed to have missing, incomplete, or inaccurate information.

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

Correction Narrative: On April 23, 2025, Operation provided documentation for Medication Management/Documentation to include training certificates for staff and administrative personnel that was facilitated by a medical professional and facility administration, and the operation provided a copy of their standardized checklist for resident record keeping used to audit their files for ongoing compliance. Operation also reported that files are being audited by the CEO and LCCA.


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

raw_content: Evening medication was prepared in advance.

Correction Narrative: On April 23, 2025, Operation provided documentation for completion of Medication Management/Documentation to include training certificates for staff and administrative personnel.  Training was facilitated by a medical professional.


raw_content: It was discovered during interviews with the children and staff that a child in care slept over at a staff member's home without the case workers knowledge.

Correction Narrative: On April 10, 2025, Licensing conducted a follow-up inspection at the operation. Two employees were interviewed and both stated that leadership has spoken with staff regarding boundaries with the children. Staff also provided a copy of the sick child & insolation policy acknowledgement. Operation further stated that should children require isolation in the future, child will be placed in the recreation room, with bedding and other items, to keep themselves and others safe.


raw_content: The Child Care Administrator was observed to not be present at the operation since the application inspection.  Additionally, the Child Care Administrator is not listed on the work schedules provided by the operation, further confirming the LCCA's absence.  It was relayed by the operation that the Child Care Administrator is a student and checks online for updates regarding the operation.

Standard Number / Description: 748.531(a)(3) - Child-care administrator-Is full-time employee of the operation

Correction Narrative:
The operation provided the following response on March 10, 2025:
Corrective Action:
- Immediate Action:
  - The current LCCA has been scheduled ensuring she meets the 30-hour requirement per standards.
  - A tracking log has been created to document the LCCA's weekly hours to ensure compliance.
- Contingency Plan:
  - Current staff is eligible to take the LCCA exam.
  - If the current LCCA does not meet the required weekly hours, the staff will assume the LCCA duties once she passes her exam and is officially licensed.
  - A transition plan will be developed to ensure a smooth transfer of responsibilities if needed.
Responsible Party:
- Current LCCA
- Executive Director
- Staff (Future LCCA Candidate)
Follow-Up & Compliance Monitoring
- The Executive Director will review the LCCA's weekly schedule and logs to confirm that the required 30-hour facility presence is being maintained.
- A compliance report will be generated at the end of each quarter to track adherence to these corrective measures.


summary: 745.4151(c)(6)(A) - Discipline-An applicant or employee's consent to submit to drug testing is required as a condition of employment

raw_content: The employee records do not contain the required consent for drug testing.

Correction Narrative:
Operation provided the following response on March 10, 2025:
Corrective Action:
- Immediate Action:
  - All current employees at JM Home Care have now signed the written consent to adhere to drug testing.
  - Each signed consent form has been placed in the respective employee files for compliance.
- Preventative Measures:
  - Moving forward, all future employees and staff members must sign the drug test consent form prior to being officially hired.
  - A checklist will be implemented in the hiring process to ensure all required forms, including drug test consent, are completed before onboarding.
  - Monthly internal audits will be conducted to verify compliance with hiring documentation requirements.
Responsible Party:
- Human Resources Department
- Hiring Manager
Follow-Up & Compliance Monitoring
- The HR Department will conduct monthly audits to ensure that all newly hired staff members have signed the drug test consent form before employment begins.
- A compliance report will be generated at the end of each quarter to track adherence to these corrective measures.

Physical follow-up not required per supervisor.


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

raw_content: The current nor discharged children records included documentation of an admission assessment.

Correction Narrative:
The operation provided the following compliance response on December 9th and updated on December 11th as noted below:

A standardized admission checklist has been developed and implemented. The checklist includes:  Verification of all required documents (e.g., medical history, educational records, behavioral assessments).  Completion of an initial placement evaluation to determine the appropriateness of the placement.  Documentation of all relevant information needed for service planning, including cultural considerations and specific support needs. We've hired a Treatment Director and who will oversee all Treatment plans. They will report directly to the Executive Director if any delays should occur. The Pre-Service Plans will be completed prior to the arrival of a new resident. 72 hour will be completed within the allotted time frame. The 30-day Service Plan will be completed as well as a Service Plan invitation to the resident caseworker and other interested party. We will have a tracker to ensure 90-days service plans are conducted in time and service invitation will be sent out. Executive Director will audit the Service Plans and ensure all parties involved receives a copy of it. This process will be reviewed quarterly to make adjustments as needed for efficiency and compliance.  Any instances of noncompliance will result in immediate corrective measures and additional staff training.


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

raw_content: Operation was present when inspector arrived and didn't have a posting.  Operation didn't make proper notification.

Correction Narrative:
The operation provided the following compliance response on December 9th and updated on December 11th as noted below:

A visible and clear sign will be placed on the front door when no one will be home for an extended period. The sign will state: No one is currently home. For immediate assistance or to gain access, please call 346-340-4306. A designated staff member will always be on call to respond to such inquiries. We are in the process of hiring a full-time office manager who will oversee the day-to-day process.  Training will be conducted with all staff to emphasize the importance of ensuring Licensing can access the operation at all times. This training will include who to contact and the protocol for when the facility is unoccupied.


summary: 748.709(b)(1) - Designated person making decisions on childhood activities must work at same location where child resides

raw_content: The name of the designated person who works at the operation is missing from the children's face sheets, only the case worker's name is listed.

Correction Narrative:
The operation provided the following compliance response on December 9th and updated on December 11th as noted below:

All child face sheets have been updated to include the name and contact information of the assigned "Normalcy Decision Maker." These face sheets are stored in a binder at the residence and are easily accessible.  A system has been implemented to ensure that only staff working at the child's residence are assigned as the Normalcy Decision Maker.  Supervisors will review and confirm the designated decision maker assignments when creating the resident file upon admission.


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

raw_content: An employee file contained an expired CPR/FA certification, and it was confirmed that the staff hasn't retaken it.

Correction Narrative:
The operation provided the following compliance plan on October 15, 2024:
Steps of the Corrective Action Plan:
1.	Development and Implementation of a Training Tracker System
o	We are launching a training and qualification tracking system to monitor expiration dates for key certifications.
o	The system will generate automated alerts at least 60 days before a certification or training expires, giving staff ample time to renew.
2.	Notification Process
o	When an expiration date approaches, both the individual staff member and their supervisor will receive email reminders and in-app notifications (if using Extended Reach or a similar software).
o	Follow-up reminders will be issued 30 days and 7 days prior to expiration if the training or certification has not been renewed.
3.	Accountability Measures
o	Supervisors will review the training status of their team members in monthly compliance meetings to ensure all qualifications remain current.
o	Any staff member who allows their certification to lapse will be placed on temporary administrative leave until the necessary qualifications are renewed.
4.	Mandatory Staff Refresher Trainings
o	In addition to tracking expirations, we will conduct annual refresher courses for essential certifications like First Aid and CPR to keep staff knowledge current.
o	Refresher trainings will also include TBRI reinforcement sessions to maintain consistent application of trauma-informed care principles.
5.	Reporting and Documentation
o	Training compliance reports will be reviewed quarterly by the administrative team to identify trends or gaps.
o	Corrective action logs will be maintained for any missed training, and a plan will be developed with the employee to prevent future lapses.
6.	Evaluation and Continuous Improvement
o	The effectiveness of the tracking system will be evaluated bi-annually, and adjustments will be made as needed to improve compliance rates and streamline processes.

CPR training was scheduled for 10/18/2025.


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: Active employee file included an affidavit that was prefilled, but it wasn't notarized.


summary: 748.3115 - Fire Extinguisher-Must inspect fire extinguisher(s) monthly

raw_content: Documentation of monthly fire extinguisher inspections were not observed on to be signed and dated on the inspection tag nor was documentation available for review indicating that a monthly inspection of the fire extinguishers has been conducted.

Correction Narrative:
The operation provided the following compliance plan and included pictures of the fire extinguishers:

Objective:
To ensure the fire extinguisher is inspected by a licensed official and that JM Home Care management ensures the tags are signed on a monthly basis. This will ensure the fire extinguisher is in proper working order.

Action Steps:

1. Inspection by Licensed Official:
    Responsibility: Designated by CEO/Executive Director.
    Action: Schedule an inspection by a licensed fire extinguisher inspector.
    Frequency: Annually.
    Documentation: Obtain a certificate of inspection and retain it in the facility log.

2. Monthly Tag Signing:
    Responsibility: Designated by CEO/Executive Director.
    Action: Assign personnel to inspect the fire extinguisher and sign the tag each month.
    Frequency: Monthly.
    Documentation: Record the inspection date and signature on the fire extinguisher tag and log the inspection in the facility log.

3. Maintenance of Documentation:
    Responsibility: Designated by CEO/Executive Director.
    Action: Maintain a dedicated log for fire extinguisher inspections.
    Frequency: Continuous.
    Documentation: Keep the log updated with inspection dates, signatures, and copies of the annual inspection certificates and receipts

4. Submission to Officials:
    Responsibility: Designated by CEO/Executive Director.
    Action: Submit the log and inspection certificates to any officials upon request.
    Frequency: As required.
    Documentation: Ensure all documentation is readily available for submission.

Designated Personnel:
The personnel responsible for the monthly tag signing and maintaining documentation will be appointed by the CEO and/or Executive Director. The list of designated personnel will be updated in the facility log.

By following this corrective action plan, JM Home Care will ensure that the fire extinguisher is in proper working order and compliant with safety regulations.


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

raw_content: The childcare administrator job description did not indicate the duties and responsibilities for which the employee was hired.  The employee signed and dated a job description that didnt reflect the roles, duties, responsibilities, nor requirements of a Licensed Child Care Administrator.

Correction Narrative:
The operation provided the following compliance response on 06/19/2024:
JM Home care has corrected this deficiency by ensuring all employee prior to hiring have a current job description signed in their personnel records. Job descriptions have all been written Executive Director.


facility_name: Amazing Touch Care Home

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

raw_content: The back yard fence had multiple board that need to be replaced. The stairs railing is loose.

Correction Narrative: RCCR inspector conducted a walk through of the operation on 12/9/25. The backyard fence was observed to be fixed and in compliance with standards. The administrator stated staff fill out a maintenance log daily when signing in and after they have completed their walk through. The fence was fixed the day of the deficiency.


raw_content: Two caregivers failed to maintain self-control and engaged in inappropriate behavior towards each other in front of the children in their care.

Correction Narrative: RCCR completed an unannounced follow up inspection at the operation.  During the follow-up, staff were interviewed and expressed that they've addressed this concern with the staff and will have ongoing meetings to ensure staff aware of appropriate communication, professionalism, and boundaries in the presence of the youth. Staff expressed that it's important to be mindful and take into consideration that children are dealing with trauma and disagreements may cause children to respond negatively. Staff are expected to maintain professionalism, appropriate boundaries, and ensure there is a therapeutic milieu at all times.


raw_content: A caregiver did not adhere to the supervision requirements outlined in the child's service plan by leaving a child on 1:1 supervision unattended for approximately 40 minutes.

Standard Number / Description: 748.685(c)(6) - Implement and follow the children's service plans.

Correction Narrative: RCCR completed an unannounced follow up inspection at the operation.  During the follow-up, staff were interviewed and expressed that they are made aware of the children's supervision requirements prior to, on the day of, and throughout their placement.  Additionally, operation will conduct ongoing monthly meetings to further discuss all children who placed at the operation. Staff will ensure that not only is everyone aware of the supervision requirements but also have appropriate coverage for ratio.   Staff also have direct access to children's files to review service plans. Staff also complete training regarding supervision and complete observation hours to ensure they are aware of appropriate supervision.


summary: 745.8411(a) - Responsibilities - Not interfere with an inspection or investigation

raw_content: During the course of the investigation, documentary and testimonial evidence indicates that the principals and collateral witnesses were briefed and prepared to respond to interview questions.

Correction Narrative: RCCR completed an unannounced follow up inspection at the operation.  During the follow-up, staff were interviewed and expressed that they've addressed this concern with the staff and will have ongoing meetings to discuss cooperation and transparency during investigations and inspections. Staff informed RCCR, that they're encouraged to not get nervous when speaking with Licensing.  Additionally, an external contractor will also have meetings and trainings with the staff for additional support and perspectives.


raw_content: The operation placed a child who was younger than the victim in the same room, against the victim's Safety Plan which clearly noted the victim should not share a room with any child younger than them.

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

Correction Narrative:
RCCR completed an unannounced follow up inspection at the operation.  During the follow-up, staff were interviewed and expressed that they are made aware of the children's behaviors and safety plans to ensure they are implemented and followed. Staff also expressed to have discussed with the individual regarding the allegations, and they will continue to have ongoing reminders and trainings every month to address ongoing information regarding children in care. The compliance response was reviewed.  Staff also have direct access to children's files and the safety plans are immediately addressed with the staff. Operation will continue having ongoing, transparent, and effective communication with Licensing to ensure operation is compliant with standards or for clarification regarding the standards per staff.

Email received advised that going forward operation will ensure the caregivers will be made aware of any safety plans regarding any new arrivals or current children at the organization. This will be done during the organizations monthly meetings which are held on the 20th day of every month. Staff will sign a sign-in sheet to verify attendance of the meeting. This will give them more knowledge and understanding of the childrens needs and treatment.


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

raw_content:
Inspector reviewed morning and evening medications logs for all children in care, randomly selected medication to count, and reviewed the training roster and medication administration-documentation training certificates.
Three medication logs were reflecting a discrepancy with the remaining medication count by 1-2 pills.

Inspector conversed with the permit holder regarding the operation's plan to ensure compliane with medication documentation.

Correction Narrative: During a follow-up inspection three out of eleven children medication logs and counts were reviewed. The medication logs and counts were accurate and in compliance. Additionally, the operation did provide training on medication to their staff. Training roster was provided and reviewed and was observed in compliance.


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

raw_content: There were no documents available for review regarding the length of time for EBI conducted.

Correction Narrative: Operation provided a compliance response stating staff will receive semi-quarterly restraint refreshers.  Additionally, the Administrator will go over the restraint report to make sure the staff has filled the restraint report out correctly and documents the intervention after the EBI.


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

raw_content: There was no documentation available for review related to the post-discussion required with child.


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

raw_content: All medication logs were evaluated, and some were observed to be missing the information required to identify the staff who administered the medication.

Correction Narrative:
On May 30, 2025, operation provided copies of the medication safety, proper documentation, proper dosage, and medication administration training certificates and the rosters.

On May 27, 2025, the operation provided the following response: All staff will be trained on the Administration of Psychotropic Medications on Tuesday, May 27, 2025, at 2:00pm.  All staff will be trained in documentation and ensure the right count and dosage of medication for each child.  The medication log will be checked daily by a quality assurance person to ensure accuracy, and all children receive their medication daily.


raw_content: Staff member pre-documented the administration of evening medication, which resulted in discrepancies in the daily medication count on multiple medication records.

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


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

raw_content: All medication logs were evaluated, and on some logs, medications were observed to be administered as required with staff names and signature, but date and time weren't documented.

Correction Narrative: Inspector reviewed morning and evening medications logs for all children in care.  All medication logs were observed to reflect the date and time the medication was administered.


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

raw_content: Several incident reports were observed to be incomplete and/or missing required information.

Correction Narrative:
Operation provided the training roster for Documentation completed on March 21, 2025.
Operation's mandatory training was rescheduled to March 21, 2025 due to children in care being on Spring Break.
The operation provided the following response on March 3, 2025:
Standard 748.311/748.2855(b)-Serious Incident Documentation/EBI Documentation-the serious incident report has been revised and corrected to include required information.  Amazing Touch Care Home has only one serious incident report that staff must complete.   This process was completed by Program Administrator, Lecia Hurst to ensure accurate and complete documentation.   The Program Administrator/ and or Program Designee will review all serious incident reports and restraint reports within 24 hours after the serious incident has occurred.  All staff are required to complete and sign/date serious incidents, and restraint reports before their assigned shift is complete.   The reports will be reviewed for true and accurate information by Program Administrator, Lecia Hurst or Program Designee within 24 hours.  All serious incidents and restraint reports will be signed by Program Administrator/Designee within 24 hours.
Mandatory Documentation training has been scheduled for all staff on March 14, 2025.


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

raw_content: A restraint report dated February 22, 2025 at 11:15 AM was not reviewed within the 72-hour timeframe which should've been by February 25, 2025 at 11:15 AM.  The supervisor date and time was blank.

Category: Emergency Behavior Intervention


raw_content: All medication logs had an inaccurate daily count due to incorrect subtraction from the starting count.

Correction Narrative: On December 16, 2024, Inspector conducted a follow-up inspection at the operation and reviewed all medication logs and counted the medication with the staff.  One medication log and the medication were observed to have inaccurate counts.  Operation provided documentation that the child refused the medication including additional attempt of refusal, and the medication log was corrected during the inspection to document the refusal, and the count was updated to reflect the accurate remaining count.


raw_content: Medication logs include the signature and a cell for staff initials. The documentation doesn't include the name of the person who administered the medication, and several dates doesn't have an initial to match the person who administered the medication.

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

Correction Narrative: On December 16, 2024, Inspector conducted a follow-up inspection at the operation and reviewed all medication logs with the staff.  All medication logs were observed to include the staff name, staff signature, and staff initials for each staff member who administered the medication.


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

raw_content: Employee files contain the names of the references and indicate that the individuals were contacted, but the pre-employment screening doesn't include the documentation of the conversations.

Correction Narrative:
The operation provided the following response on November 30, 2024:
The personnel record will now have documented proof of the conversation. If the references were contacted with no response, it will also be annotated in personnel records. The correction was emailed to the Residential Child Care Licensing Inspector on November 30, 2024.


raw_content: Active employee file didn't include a notarized affidavit..

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

Correction Narrative: The following compliance plan was provided by the operation on Saturday, June 8, 2024: A Notarized affidavit was emailed to Residential Child Care Licensing Inspector on 06/06/2024. The affidavit was completed on 06/06/2024. All staff who apply for a position at Amazing Touch Care Home will be required to get the affidavit notarized during the initial application process. The Program Administrator and Program Director will ensure the affidavit is notarized before we move forward with the hiring process which includes submitting the background check and pre-service orientation.


summary: 748.3019(b) - Pest Control--Operation must use pest control operator licensed by TSPC Board or Dept. of Agriculture to prevent, control, eliminate pest infestations

raw_content: The second level of the home was observed with wasps nests outside of the home.

Correction Narrative: The following compliance plan was provided by the operation on Saturday, June 8, 2024: Photographs of the wasp nests removal were emailed to the Residential Child Care Licensing Inspector on 06/06/2024. The wasp nest was removed on 06/06/2024. The Program Administrator, Program Director, and Maintenance supervisor will complete a daily facility inspection at Amazing Touch Care Home of the interior and exterior to ensure compliance. The facility inspection forms will be kept in a binder located in the staff office and available upon request.


facility_name: Beacon Of Light Residential Treatment Center LLC

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

raw_content: No serious incident reported was provided to licensing for review.

Correction Narrative: The administrator emailed RCCR Inspector the serious incident report according to the follow-up instructions provided by RCCR Inspector.


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

raw_content: The child's service plan, suicide screening assessment, and medical documentation was provided to licensing for review.

Correction Narrative: The administrator emailed RCCR Inspector the documentation requested according to the follow-up instructions provided by RCCR Inspector.


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

raw_content: One staff was identified as not having a background check run under the current operation.

Correction Narrative:
On 06/05/25, The operation administrator emailed licensing their compliance plan.

The operation states: A background check was submitted the same day, and documentation has been updated accordingly and sent to the license representative on 06/05/2025. The issue resulted from a clerical oversight during the onboarding process, where the staff member's prior background check was mistakenly assumed to be valid under the current operation.

A new Pre-Employment Compliance Checklist has been implemented, which includes verification of background check submission specific to the operation.

Documents: The revised admission checklist has been uploaded to document library.


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: Child records reviewed indicate Suicide Screenings not completed at admission.

Correction Narrative:
On 06/05/25, The operation administrator emailed licensing their compliance plan.

The operation states: Any identified risk factors were addressed immediately with a corresponding safety plan implemented and communicated to all direct care staff. The admission checklist has been revised to include a clearly marked and required step for suicide screening. Intake will not be considered complete until this screening is submitted and reviewed by a supervisor.

Documents submitted: screenshot of Background check submitted on 06/05/25, and Background Check Eligibility Determination Letter have been uploaded to document library.


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

raw_content: Documentation provided by the operation includes two individuals with effective termination dates of March 5, 2025, but their background checks are still active as of April 14, 2025.

Correction Narrative:
After further review: The following response was provided by the operation on April 22, 2025: There was a miscommunication regarding the status of two employees listed in the central background check system. Both individuals remain on staff but are not currently on the schedule. To help prevent this issue from occurring, we will now include the removal of employees from the background check validation system as a standard part of our termination procedure. There was a miscommunication regarding the status of two employees listed in the central background check system. They remain on staff but are not on schedule.
It is important to ensure that all individuals who are no longer associated with the Beacon Of Light operation are inactivated from the background check system within seven (7) days of their termination. To prevent this issue from recurring, we will now include the removal of employees from the background check validation system as part of our standard termination procedure

On April 21, 2025, the operation provided the following response: It is important to ensure that all individuals who are no longer associated with the Beacon Of Light operation are inactivated from the background check system within seven (7) days of their termination. To prevent this issue from recurring, we will now include the removal of employees from the background check validation system as part of our standard termination procedure.


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

raw_content: Operation did not notify Licensing when an individual ceased to be a controlling person with their operation whom they confirmed was no longer in their role as of 8/12/24. This individual was not removed until 08/22/24, when confirmation was received via email.

Correction Narrative:
The operation provided the following action plan on 08/27/2024:
The LCCA will send an email to Licensing if a person ceases to be a controlling person at Beacon of Light RTC.  The email will be sent no later than 48 hours after a person has been removed.  The email will state the name and title of the removed individual, the effective date of removal and the reasons for removal.  A copy of this email will be kept in the LCCA's office to be reviewed if needed.


facility_name: Blessed Kidz Residential Treatment Center, LLC

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: During the inspection of the vehicle the registration sticker for the vehicle was expired as of 12/25.

Category: Transportation

Correction Narrative: The following compliance plan was received on 1/27/26 by the administrator via email: Each vehicle used must be registered and have a current inspection sticker for the state in which it is registered. Moving forward the operation's administrator will ensure that the vehicle registration will be purchased before the end of the expiration date by placing a reminder on their calendar of its due date going forward. The registration sticker has been secured, and a picture has been sent to licensing.


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

raw_content: There is a cracked tile on the bottom floor and the flooring on the top floor is not well-maintained. Additionally, the return air vent has a build up of dust on the grate. There is mold/mildew in the upstairs bathroom.

Correction Narrative: The following compliance plan was received on 1/27/26 by the administrator via email: The operation's Administrator will do a weekly walk through the home to ensure that everything is in good repair and there are no tripping hazards.


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

raw_content: During the walk through there were 4 child beds missing mattress covers.

Correction Narrative: The following compliance plan was received on 1/27/26 by the administrator via email: The operation's staff members will check for mattress covers once a week to ensure that the children have not discarded them and replaced them.


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 members engaged in a verbal altercation in the presence of children in care.

Correction Narrative:
A conversation with the owner held on 06/17/2025 indicated she spoke with both staff and provided the option of one going to work at the other facility and also directly reporting to her as supervisor.

On 08/18/2025 an email received from Administrator with a letter stating the staff involved in the verbal altercation is no longer employed at the operation and her last day was July 16, 2025.

Staff no longer employed at the operation was verified as inactive in CLASS.


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

raw_content: During an investigation it was discovered that a resident in care was absent from the facility without the knowledge of staff for over an hour.

Correction Narrative: 748.685(a)(4) Caregiver responsibility -Blessed Kidz staff has been retrained by the Administrator on providing the level of supervision necessary to ensure each child's safety and well-being


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: During an investigation medical records requested, had incomplete logs of the residents refusing or taking medicine.

Correction Narrative: The operation provided completed log that indicates resident taking medication or refusing to take medication and it was signed and dated by caregiver who administered the medication.


raw_content: An employee, who is no longer employed at the operation, as of 11/23/2024, still have an active background check.

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

Correction Narrative:
The operation provided the updated response on December 4, 2024:
Blessed Kidz will ensure that each employee is deactivated in the system upon termination or their exit from employment. The administrator will inactivate each employee that is no longer associated with the operation within 7 days of them leaving

The operation provided the following response on December 3, 2024:
Blessed Kidz will ensure that each employee is deactivated in the system upon termination or their exit from employment.


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

raw_content: Expired medication dated 11/24/2024 was still in the medication bin on 12/03/2024.

Correction Narrative:
Operation provided the discontinued medication log on 12/16/2024.  Supervisor approval was received to not conduct a follow-up.

The operation provided the following updated response on 12/04/2024:

Blessed Kidz will ensure that all expired meds will be inventoried and stored separately from current meds by logging the dates of expiration and discarding appropriately. The administrator will ensure that the medication that is taken by the residents are still valid and will properly discard any expired medication.

The operation provided the following response on December 3, 2024:

Blessed Kidz will ensure that all expired meds will be inventoried and stored separately from current meds by logging the dates of expiration and discarding appropriately.

After the inspection ended, the Inspector observed the Administrator inventorying and discarding the expired over-the-counter medication.


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 unlocked and accessible to children.

Correction Narrative:
Inspector conducted a physical walkthrough of the operation, and all chemicals and/or poisonous items were observed to be locked, stored appropriately, and inaccessible to children in care.

The operation provided the following response on November 13, 2024:

Blessed Kidz RTC will ensure poisonous/flammable material is stored in an area that is inaccessible to children unless child is capable to use responsibly by training staff to make sure it is locked away in a closet with the other chemicals.


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

raw_content: Two medication logs were observed to be blank for the reason for the prescribed medication.

Correction Narrative:
The operation provided the following response on November 26:

Blessed Kidz RTC will ensure that the reason medication was prescribed is clearly indicated on the medication log by checking each one individually.


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

raw_content: Serious incident report is documented as N/A where the information should include information for each child involved in the incident.

Correction Narrative:
The operation provided the following response on November 26, 2024:
Blessed Kidz RTC has provided additional training and a template to ensure the Serious Incident Documentation includes the name, age, gender, date of admission and any other required information for all children involved in an incident.


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

raw_content: Staff member put children at risk of harm by allowing the children to intervene when attempting to de-escalate an incident and in an emergency situation.

Correction Narrative:
Inspector conducted an inspection at the operation, and the operation continues to provide training to caregivers and ensuring that only staff members perform caregiver duties and redirect children as needed. Inspector monitored the behaviors and interactions of the children and staff. Inspector didn't observe staff members to allow children to perform caregiver duties during the inspection, and none of the children were observed attempting to perform caregiver duties.

The operation provided the following response on November 26, 2024:

Blessed Kidz RTC will provide additional training to ensure the caregiver will provide a safe environment for all children in care.


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

raw_content: Nearly all documents provided were observed to be incomplete and/or partially provided and an incident report was unable to be located.

Correction Narrative:
The operation provided the following response on November 26, 2024:
Blessed Kidz RTC has provided training and templates to all staff to ensure that the records are current, complete, true and accurate as reflected in its operational responsibilities.


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

raw_content: Seven of seven medication log do not include the name and signature of the staff member who administered the medication.  Only one medication log has a staff name, signature, and initial but the initial doesn't belong to any of the staff initials on the dates the medications were administered.

Correction Narrative:
The operation provided the following response on November 26, 2024:
Blessed Kidz RTC has provided training on including the name and signature of the person administering the medication.


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

raw_content: During the inspection it was observed that the emergency evacuation diagram postings do not have anything to indicate where the children and staff should shelter in place during threatening weather.

Correction Narrative: Inspector conducted a physical inspection at the operation, and operation had the correct emergency evacuation route that was approved during the standard by standard, and it includes the shelter in place which is indicated by a black dot with a legend to include this information.  Emergency evacuation route was observed to be posted in all required areas.


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

raw_content: The annual summary log was observed to be missing all of the required criteria and only outlined the child's name, date of abscense, return date & hotline report confirmation number.

Correction Narrative: On October 22, 2024, a physical inspection was conducted at the operation.  During the inspection, the operation provided a copy of the unauthorized absence log, that was approved, during the standard by standard.  The unauthorized absence summary log has all of the required components per §748.453.


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

raw_content: During the inspection in  bedroom 3 it was observed that there were no blinds or curtains.

Correction Narrative: During the follow-up inspection, the inspector observed all windows to include curtains, blinds, or shades and there was no concern noted for privacy in the children's bedrooms.


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

raw_content: During the inspection it was observed that  in bedroom three, the window was broken. In place of the glass there is a plexy glass glued to the barrier of the window pane, and is not completely glued on.

Correction Narrative: During the on-site inspection, inspector observed a repaired window in bedroom three.  There wasn't evidence of broken glass nor hazards.


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: A child in care was not administered a suicide risk screening on the date of admission.

Correction Narrative:
The operation provided the following compliance response:

Solution to Comply with Standard: In order to comply with this standard moving forward, the facility has made the ASQ a part of the intake process by adding it to the admissions checklist. This will ensure that the ASQ is not overlooked and is completed at time of intake.


facility_name: Haven of Rest Care Home II

summary: 748.885(5) - General pre-service training curriculum-Must include training on related policies and procedures.

raw_content: Two staff did not receive the additional medication training required when the DFPS training is used.

Correction Narrative: An email was received from the Executive Director indicating that the operation has secured two healthcare professionals, one RN and PharmD to provide the required training on medication administration.  In addition, they have scheduled two additional training throughout the year as a refresher for staff. This is also to ensure that all staff are knowledgeable on medication management, handling/storage and administration. Training sign in sheets were received indicating that the training was completed on 01/15/26.  The training certificates were uploaded.


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

raw_content: A child in care was given another child's medication. There were no side effects.

Correction Narrative: A training was conducted regarding medication.Staff were interviewed and determined that the training was conducted  ensuring the proper medication is given to the correct child. Medication and documentation was reviewed.


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

raw_content: An out of state background check was not completed on a caregiver that had access to the children.

Correction Narrative: An email was received from the Executive Director indicating that the management team will review all prior employments on applications to ensure the accuracy of ensuring background checks for out state are completed. The out of state background was ran on 12/09/25.   In addition, a plan has been put in place to ensure all the conditions are met during the provisional timeframe.


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

raw_content: The operation did not follow a child's service plan regarding supervision.

Correction Narrative: The sign in sheets were reviewed for the training that was provided to the staff. In addition, an interview was conducted with staff confirming training was provided and they understood what to do with supervision and if an emergency arose what to do.


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

raw_content: It was observed that there were several holes in the operation, dust on the ceiling fan, air vents, and mold on baseboard.

Correction Narrative: The facility corrected all the areas that were identified during the initial walk through.  Pictures were taken of the corrected and areas.


facility_name: Sunshine Youth Haven 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: Medications were observed in an unlabeled container.

Correction Narrative:
The employee was counseled on proper documentation and medication handling procedures and demonstrated understanding of the corrections.
The employee will complete refresher training on Medication Administration and Documentation Standards, emphasizing:
	Proper medication storage and labeling requirements.
	Accurate and timely completion of all MAR fields at or within two hours of administration.
	Maintaining documentation integrity and accountability for medication counts..
To ensure continued compliance, the employees medication administration practices will be monitored for 30 days. Supervisors will review all MAR entries at the end of each shift during this period to verify accuracy, completeness, and timeliness.
In addition, the Medication Administration Policy will be reviewed with all staff during the next scheduled team meeting to reinforce proper procedures and prevent recurrence.
Expected Outcome:
Following retraining, policy review, and supervisory oversight, the employee is expected to demonstrate full compliance with Sunshine Youth Havens medication storage and documentation policies. All medications will remain in their original labeled containers (or properly labeled secondary containers when authorized), and all medication records will be completed accurately within two hours of administration.
The corrective measures takenincluding the removal of all pill holders from the facilityare designed to ensure continued compliance with state licensing standards, strengthen accountability, and support the employees professional growth.


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

raw_content: A child in care was sent to school in possession of psychotropic medication to give the school nurse.


facility_name: Grace Alpha Focused Care LLC

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

raw_content: Operation had broken television outside in back yard.


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

raw_content: Two child records reviewed and various forms from the child records requested and not available at this time. Placement agreements for two child records reviewed were not available. Medical consenter for both child records. Orientation for both the child records. Placement agreement for both child records.

Correction Narrative: The second citation was issued for missing placement paperwork. At the time the child was admitted, it was immediately prior to the Christmas holiday. We made multiple attempts to obtain the required placement documentation by emailing both the assigned caseworker and supervisor. While some paperwork was provided, several required documents remained outstanding. Due to the holiday timeframe, we did not receive a timely response despite our continued outreach.


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: During the course of this investigation, it was determined that a staff member told the child they were at risk of losing placement as well as contacted LE and their guardian requesting them to pick up the child due to their behavior.

Correction Narrative: An unannounced follow-up inspection was conducted on 12/16/2025. One child in care was interviewed and reported no concerns. The child reported they feel safe, and staff treat them well and do not threaten loss of placement. Two staff members were interviewed and reported a training was conducted to review children's rights and discipline and punishment.  The administrator reported staff were trained on respecting the children's rights and to be calm and patient with the children in care as well as de-escalation. The sign in sheets for the training and the power point was provided. No concerns were observed throughout the walkthrough of the facility.


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

raw_content: It was determined that a staff member yelled at a child in care in an attempt for the child to be redirected and minimize inappropriate behavior.

Correction Narrative:
11/19/2025: As per the operation's Administrator/LCCA, all GAFC staff were retrained on the applicable Texas Minimum Standards, including discipline and punishment guidelines, prohibited punishment practices, child rights and protections, appropriate staff interactions and supervision expectations, and maintaining a safe, trauma-informed environment. A training PowerPoint and staff sign-in sheet were provided as documentation of completed corrective action.

An unannounced follow-up inspection was conducted on 12/16/2025. One child in care was interviewed and reported no concerns. The child reported they feel safe, and staff treat them well and respectfully. The child stated staff do not yell, or disrespect them in anyway. Two staff members were interviewed and reported a training was conducted to review children's rights and discipline and punishment. The administrator reported staff were trained on respecting the children's rights and to be calm and patient with the children in care as well as de-escalation. Discipline at the facility includes loss of privileges. Staff reported there is no corporal punishment or yelling at the children in care at the facility. The sign in sheets for the training and the power point was provided. No concerns were observed throughout the walkthrough of the facility.


facility_name: HAID LLC

raw_content: A caregiver used informal language when addressing a child about his behavior.

Correction Narrative: This standard was observed to be compliant during a follow-up visit.


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

raw_content: During the walk-through of the operation, one toilet was not clean and two shower curtains had feces on them.


summary: 748.2855(a)(3) - EBI Documentation-Must include the de-escalation attempted before and during the use of EBI and the child's reaction to those strategies

raw_content: Review of two charts found several required areas missing off the EBI Documentation or were documented incorrectly.


summary: 748.2857(a) - No later than 72 hours after the initiation of the intervention, you must provide written notice to the parent.

raw_content: Review of 2 charts showed one of the notifications was missing all the required information and the other EBI was not reported.


summary: 748.303(a)(2)(B) - AP Serious Incdt- Report to parents any injury/illness that warrants treatment from a medical prof. directly after ensuring the safety of the child.

raw_content: During the investigation, it was discovered the operation failed to report the child's injury to the parent entity in a timely manner.

Correction Narrative: On 9/18/25, the administrator of the operation finalized the correction plan, indicating she would be retraining her staff regarding proper reporting procedures and timeframes.  She identified the staff to be receiving the training and stated the training would be completed by 9/24/25 due to this being the earliest scheduling availability.  A copy of this email thread has been uploaded to document library for this investigation.  This training can be referenced in future monitoring efforts for compliance.  This plan will bring this standard back into compliance.


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

raw_content: One out of four medication count was documented incorrectly.

Correction Narrative: Staff was retrained on 07/30/2025 by the operations nurse. Sign in roster was provided. During new staff training the nurse will provide the training and retrained every three months. Staff will also conduct weekly audits to ensure documentation is accurate.


summary: 748.311(7) - Serious Incident Documentation-Includes circumstances surrounding the incident

raw_content: All serious incidents reviewed did not have the health care provider information, intervention, and circumstances surrounding the incident documented.

Correction Narrative: The operation will be using HHSC form 2991. The staff will also conduct monthly audits to ensure all required documentation is available.