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

raw_content: Per the mental health provider recommendations, safety plans implemented to maintain the safety of the child were not followed, as the child was not provided with the 1 on 1 supervision as the operation did not have enough staff and recommended 15 minute checks in and did not make arrangements to provide the 1 on 1 supervision for the child.

Correction Narrative:
The previous allegations are being disputed via administrative review and any submission or compliance with a plan of action/ correction does not constitute an admission nor a waiver of any and all due process rights concerning this investigation.

While SJRC Texas is currently disputing the allegations concerning the citations at issue through administrative review and due process, SJRC Texas has reviewed all polices and the procedures regarding campus supervision, documentation, and reporting serious incidents specifically: 4.14 Adult Supervision of Youth, 1.5 Reporting Serious Incidents, and 4.3 Youth Referrals to Community Service Providers. A full review, timeline, and analysis has been conducted regarding these citations and the incidents that led to them. As a result of the Ineligible status of the two named employees, both were terminated while they request and await their Administrative Review and due process.

Our program has also reviewed the procedures for increased supervision and safety plans. While SJRC Texas continually meets the requirements for supervision, the Treatment Team will convene in these types of incidences to decide if a youth is in the appropriate placement due to the supervision needs requested of mental health professionals or regulatory agencies. As this facility is a General Residential Operation and not an RTC, the supervision available may not be suitable for sustained periods of time. If this is the case, the SJRC Treatment Team will work with the mental health professionals or regulatory agencies to request their approval for an expedited change in placement.


state: TX

facility_name: SJRC Texas, Inc.

summary: 748.303(a)(12)(B) - Serious Incident-Report to parents immediately after ensuring the safety of the child any suicide attempt by their child.

raw_content: Operation staff did not notify child's CPS worker/parent about the two suicide attempts made by child in care while at the operation.

Category: Individual Standards Evaluated

Standard Risk Level: Medium

Corrected at Inspection: No

Correction Narrative:
The previous allegations are being disputed via administrative review and any submission or compliance with a plan of action/ correction does not constitute an admission nor a waiver of any and all due process rights concerning this investigation.

While SJRC Texas is currently disputing the allegations concerning the citations at issue through administrative review and due process, SJRC Texas has reviewed all polices and the procedures regarding campus supervision, documentation, and reporting serious incidents specifically: 4.14 Adult Supervision of Youth, 1.5 Reporting Serious Incidents, and 4.3 Youth Referrals to Community Service Providers.

A full review, timeline, and analysis has been conducted regarding these citations and the incidents that led to them. As a result of the Ineligible status of the two named employees, both were terminated while they request and await their Administrative Review and due process.

Our program has also reviewed the procedures for increased supervision and safety plans. While SJRC Texas continually meets the requirements for supervision, the Treatment Team will convene in these types of incidences to decide if a youth is in the appropriate placement due to the supervision needs requested of mental health professionals or regulatory agencies. As this facility is a General Residential Operation and not an RTC, the supervision available may not be suitable for sustained periods of time. If this is the case, the SJRC Treatment Team will work with the mental health professionals or regulatory agencies to request their approval for an expedited change in placement.


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

raw_content: Operation failed to report two suicide attempts to licensing for a child in care who was evaluated and put on a safety plan when returned to operation.

Standard Risk Level: Medium High


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

raw_content: During the investigation Austin Welch admitted, he signed the observation logs for the child, however, also admitted he did not complete the supervision checks, he only signed the logs and did not check on the child himself.


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

raw_content: According to medication logs, a child in care did not receive one medication for one day and did not receive another medication for two days as prescribed.

Correction Narrative: An email was received stating that SJRC Texas understands the importance of following both the prescribing physician's orders as well as its own procedures around medication distribution and medication discontinuation. These practices were immediately reviewed with the residential staff and management team. Medication records are now also being audited in a more in depth manner that will hopefully educate employees as well as aid in catching these potential medication errors as they occur.


summary: 748.4001(b) - General requirements-must ensure the safety of all children during any transportation that the operation provides

raw_content: During the unannounced inspection, transportation vans for Harvery House were found to have broken seatbelts.  While inspecting the vehicles for A-Wing, another seatbelt was found to have a broken cover to the buckle.

Category: Transportation

Standard Risk Level: High

Correction Narrative: Per documentation provided by the operation, an admin review has been requested for all deficiencies.


summary: 748.3115(3) - Fire Extinguisher-Must ensure fire extinguishers are serviced as required by manufacturer's instructions, or as required by fire inspector

raw_content: During the full walkthrough of the Hall House, a fire extinguisher was found to be out of compliance with the inspection tag being ripped in half. Also the gauge showed inadequate pressure.

Category: Safety and Emergency Practices


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

raw_content: During the walkthrough of Hall House, the thermometers in the freezer were found to be reading at 32 degrees F. The thermometer in the refrigerator was found to be given an inaccurate reading.


facility_name: Heartlight Ministries

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

raw_content: During the inspection, we observed three of four children's medication records to include medication logs with initials for ther person administering medications but not the full names of those individuals.

Category: Medication

Correction Narrative: On 4/10/26, the operation submitted a memo circulated to all staff members which reiterates the minimum standard requiring staff to include name and signature of each person administering medications.  The memo is dated 4/8/26 and addressed to all staff.


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

raw_content: During the inspection, I observed one of the beds in a boys cottage lacked a mattress cover.

Correction Narrative: On 10/3/25, the operation provided photographic evidence of the mattress cover installed on the bed.   This brings this standard into compliance.


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

raw_content: During the walkthrough, I observed broken tiles in the upstairs bathroom floor of a girl's house.

Correction Narrative: On 10/9/25, the operation provided a copy of the invoice documenting the proposal from a third party vendor to repair the tiles in the bathroom.  The invoice states all repairs will be scheduled to begin 10/20/25 and completed by 10/24/25.  This brings this standard into compliance.


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

raw_content: A child suffered an injury on 5/21/2025 while playing basketball, however, the child was not taken to seek medical attention until 5/29/2025. When the child was seen by medical, he was diagnosed with a closed fracture.

Correction Narrative: On 7/24/2025, the operation's Administrator provided the following correction via email: The standard states that a child in care must receive medical care as needed for injury, illness and pain.  I would like to note that the child did receive medical care for the injury as noted by the documentation that you have already received.  I did not see in the standard listed any specific time frame for a response time.


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

raw_content: Licensing was not notified within 24 hours of a child's diagnosed fracture. The diagnosis was provided on 5/29/2025 at approximately 530pm, however, the report to SWI did not occur until 5/30/2025 at approximately 630pm.

Correction Narrative: On 7/24/2025, the operation's Administrator provided the following correction via email: I will remind all on-call persons that we have to file the occurrence no later than 24 hours.  The person who was on-call for this incident will be written up for the infraction, because it is known that we have a 24-hour window.  I will go back over this standard with everyone that is on-call.


summary: 748.863(a)(5) - Pre-Service Training- Caregivers who administer medication must have psych medication training before administering psych meds.

raw_content: During the inspection, we observed five of six employee files lacking the requisite administrating psychotropic medications training.

Category: Training and Professional Development

Correction Narrative: On 5/8/25, the operation submitted a plan indicating all residential staff, both residential directors, and the medication director will be retrained in administering medications on 5/13/25.  The name and credentials of the individual conducting the instructor led training were submitted and satisfactory.  The plan notes the operation will update their training protocols for new hires to ensure a medical professional leads the training for all new hires as well.  This brings this standard into compliance.


raw_content: During the inspection I observed three resident beds that lacked mattress covers.

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

Category: Physical Site

Corrected at Inspection: Yes


raw_content: During the inspection, I observed mildew in the wooden shower and bathroom walls and celings of four cottages. A shower in one of the houses exhibited low water pressure.

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

Correction Narrative: A follow-up inspection was completed to verify deficiencies observed on 2/21/2025, were corrected. No additional concerns observed on this date.


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

raw_content: During the walkthrough, I observed missing trim with exposed nails inside a cabin bathroom and damaged drywall around the entry to a bedroom in another cabin with exposed corner protectors and around the window.


raw_content: During the investigation inspection, the dishwasher in New Lodge was observed to be dirty and a bathroom wall had mold/mildew.

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

Correction Narrative: On 1/29/2025, the operation's Assistant Director provided photographs to reflect a new dishwasher was installed to replace the old dishwasher, and mold/mildew on bathroom wall has been corrected.


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:
During the investigation inspection, it was discovered that
New Lodge had a used fire extinguisher. According to staff and documentation the fire extinguisher was used eight days prior, and a request was submitted for a new one; however, the extinguisher for this Lodge has not been replaced yet.

Correction Narrative: During the follow-up inspection, I observed two fire extinguishers in the lodge that were fully charged and were in date.  The discharged or undercharged extinguishers had been removed from the building.


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

raw_content: Children in care were able to secure tools from restricted areas at the operation- which enabled them to dismantle the window in their cottage and engage in illegal activities.

Correction Narrative: An email was received on 12/18/24 from Blake Nelson. They are retraining staff on supervision and stressing the importance of appropriate language in front of and in the vicinity of the residents. An inspection will be completed, as this is a high-weighted citation.   A follow-up inspection was completed on 12/19/24 showing compliance by the staff areas being locked, ratio intact, and no MSV.


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

raw_content: During the walkthrough, I observed the following physical site issues to be in compliant:  A shower head in one of the resident bathrooms was broken and needed replacing, a small closet/storage area door in one of the cottages was broken with exposed nails, the cabinet in the laundry room of one cottage has been broken with a maintenance report on file since 7/27/24, a toilet in one cottage lacked a tank lid with a maintenance report filed 9/2/24. I observed the following to still be deficient and an extension is being granted: shower surround in one bathroom evidenced a peeling backing board above the shower surround,and  a broken bathroom door. I observed a new deficiency during my walk through. There wa drywall damage in Vickie's Main half bath.

Correction Narrative: During the walkthrough, I verified the physical site deficiencies yet unfinished in the previous follow-up have been completed.  This standard is now in compliance.


summary: 748.3393(d) - Toilets-Toilets must be equipped with toilet paper at all times

raw_content: During the inspection, we observed a bathroom in one of the lodges lacking any toilet paper.

Standard Risk Level: Medium Low

Correction Narrative: During the inspection, I observed a toilet paper in the bathroom in one of the lodges that was lacking toilet paper.


raw_content: During the walkthrough, we observed the following physical site issues:  A shower head in one of the resident bathrooms was broken and needed replacing, shower surround in one bathroom evidenced a peeling backing board above the shower surround, a small closet/storage area door in one of the cottages was broken with exposed nails, the cabinet in the laundry room of one cottage has been broken with a maintenance report on file since 7/27/24, a toilet in one cottage lacked a tank lid with a maintenance report filed 9/2/24.  Items with maintenance reports on file are not being completed in a timely manner.

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


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

raw_content: During the walkthrough, I observed two freezers in one of the houses has replaced the missing thermometers.


summary: 748.3443(a)(6) - Food Preparation-Food items must be covered when stored in the refrigerator

raw_content: During the walkthrough, we observed uncovered food in the refrigerator of one of the cottages.

Correction Narrative: During the walkthrough, I observed no uncovered food in the refrigerator of the cottage.


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

raw_content: During the walkthrough, we observed two bathrooms lacking handtowels in the restrooms.

Correction Narrative: During the walkthrough, I observed two bathrooms that was lacking hand towels in the restrooms to now have hand towels for each resident or a roll of paper towels.


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

raw_content: This deficiency was noted as part of a DFPS investigation.

Correction Narrative: On 8/2/24, the operation submitted corrections stating the staff in question was not permitted sole supervision of residents through the investigation.  She and all other staff were retrained in safe handling, storage, and usage of harmful chemicals and the expectations of supervision for residents on restriction status as reflected in their policies.  The staff was written up.  These topics will continue to be covered with the Residential Directors and House Directors during group meetings and one-on-one meetings so they may continue to review them with staff.   The staff member specified in the incident was terminated on 8/2/24.


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

raw_content: During the DFPS investigation, it was discovered the operation failed to properly supervise children in care, resulting in the children being able to "cheek" medications as well as crushing and snorting medications brought home from the hospital.

Correction Narrative: The operation submitted a correction plan on 8/2/24 stating they have conducted a retraining with all staff regarding how to do medication checks after a child has taken their meds.  The house in question has also added the additional step of utilizing a flashlight to look in the children's mouths.  The staff involved in the incident were written up, and one of those staff has been terminated.  The operation will continue to train and review the importance of being aware with all residential staff and remind them to keep their senses heightened when children have been off property.


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: During the DFPS investigation, it was discovered the operation failed to secure poisonous cleaning supplies, allowing children unsupervised access.

Correction Narrative:
On 8/14/24, an unannounced follow-up inspection confirmed chemicals were properly stored.  No concerns were noted regarding hazardous materials.  This brings this standard into compliance.

On 8/2/24, the operation provided a correction plan stating the administration retrained all staff on the importance of supervision for residents using harmful chemicals with all staff as well as supervision expectations for residents on restriction status utilizing harmful chemicals.  The operation terminated the employment of the staff responsible for the incident.


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

raw_content: During the investigation inspection, the thermometer located in the East House freezer indicated the freezer was at 16 degrees Fahrenheit, and not at the required 0 degree Fahrenheit or below.  Additionally, the thermometer located in Vickie's House refrigerator indicated the refrigerator was at 45 degrees Fahrenheit, and not at the required 40 degree Fahrenheit or below.

Correction Narrative: The Executive Director/Administrator provided an email with the operation's plan for correcting the deficiency. He advised they will issue a reminder to all house staff and Residential staff to look at the temperature of the refrigerators and freezers as they are pulling out food to prepare and report any changes from the 40 degrees for the refrigerator and 0 degrees for the freezer so that appropriate actions can be taken.  They replaced the refrigerator at Vicki's to help solve this issue. Photos were provided to confirm corrections were made address thermometers were at the required temperatures.


summary: 748.3443(a)(1) - Food Preparation-Food items must be covered & stored off the floor

raw_content: During the investigation inspection, there was potatoes stored on the pantry floor of New Lodge and Vickie's House.

Correction Narrative: The Executive Director/Administrator provided an email with the operation's plan for correcting the deficiency. He advised they have already and will continue to remind the residential staff that food cannot be stored on the floor.  They will continue to monitor through routine inspections.  The maintenance staff have been asked to add shelving to the floor to eliminate this issue. Photos were provided to confirm corrections were made and food is no longer stored on the floor of the pantry.


raw_content: During the investigation inspection, there was mold/mildew observed in the bathroom of the East House and Old Lodge. There was also sheet rock damage observed a bathroom located in the East House.

Correction Narrative: The Executive Director/Administrator provided an email with the operation's plan for correcting the deficiency. He advised they will reiterate with residential staff, House Directors and Residential Directors that all damage and any mildew needs to be communicated through a maintenance request to the appropriate maintenance staff.  I will remind maintenance staff that all orders need to be handled in a timely manner.  We will also remind the Residential Directors to be looking for these things as they check houses and report anything to maintenance staff as well. Photos were provided to confirm corrections were made to mold and sheet rock.


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

raw_content: During the investigation inspection, there was a first aid kit stored, unlocked and accessible to children, in the bathroom of the East House. The first aid kid contained topical creams and cold compress both of which were labeled to keep out of reach of children.


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

Correction Narrative: During the investigation inspection, it was observed the four showers located in the East House only had lukewarm/room temperature water for the children to shower. During the follow up inspection, the deficiency was observed to have been corrected.


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

raw_content: This concern arose during the course of the DFPS investigation, based on a review of the evidence obtained, a staff member restrained a child about the head or throat area during a restraint.

Correction Narrative: The operation indicated they would meet with the responsible staff and provided proof of write-up for said staff.  He will not be allowed to intervene with EBI in any circumstances other than a clear emergency. Administration will review restraint expectations with all staff.


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

raw_content: This concern arose during the course of the DFPS investigation, based on a review of the evidence obtained, a staff member utilized restraint as a means to gain compliance from a child that refused to leave a peer's room.

Correction Narrative: The operation indicated they would meet with the responsible staff, and he will be written-up.  He will not be allowed to intervene with EBI in any circumstances other than a clear emergency.  The operation will review the appropriate reasons to utilize restraints with all staff.


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

raw_content: This concern arose during the course of the DFPS investigation, based on a review of the evidence obtained, staff initiated restraints for in non-emergency situations.

Correction Narrative: The operation indicated they would meet with the responsible staff, and he will be written-up.  He will not be allowed to intervene with EBI in any circumstances other than a clear emergency.  The operation will review the requirement of an emergency situation when initiating EBI with all staff.


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

raw_content: This concern arose during the course of the DFPS investigation, based on a review of the evidence obtained, a safety plan established on 5/16/24 indicated a specific staff member would not administer restraints until the close of the ongoing investigation, but documentation indicates the staff member engaged in a restraint on 6/11/24.

Correction Narrative: The operation  provided proof of writing-up the staff that completed a restraint while prohibited by safety plan, and indicated the operation would review restraint expectations with him and all staff members.  The responsible staff was noted as being prohibited from utilizing EBI except in emergency situations wherein a child's life may be in danger.


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

raw_content: This concern arose during the course of the DFPS investigation, based on a review of the evidence obtained, a staff member failed to secure a box of over-the-counter medication stored in the staff office, resulting in a resident accessing and ingesting the medication without supervision.

Correction Narrative: A walk though of the staff office in the East House was completed on this day. There were no medications observed. The staff who had the OTC mediation is no longer employeed with the operation.


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

raw_content: During the ANE investigation, it was discovered that five of six residents interviewed reported staff cursing and yelling at them.

Correction Narrative: The operation provided a written plan to write-up the staff in question and will review expectations for appropriate communications.  The operation also offers small groups for the staff to attend that provide counseling options for staff members.  The administration will also offer additional training.  The staff self-terminated employment following the meeting.


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

raw_content: During the inspection, I observed a drainage issue in the sink of one cottage, a toilet holding human waste that did not cycle when tested in another cabin, and a cracked shower stall in a third cabin.  None of these repairs had work orders filed on them at the time of the inspection.

Correction Narrative: On 3/27/24, the operation provided pictures and a narrative detailing the repairs completed on the sink, toilet, and shower, bringing this standard into compliance.    A copy of this email and pictures can be found in Document Library.


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

raw_content: During the walkthrough, I observed excessive dust and cobwebs and cracked paint near the ceiling in one of the bedrooms.

Correction Narrative: On 3/27/24, the operation provided an email and photographic evidence of the correction to the dust and cobweb issue noted in the citation.  A copy of this email and pictures can be found in Document Library.  This brings this standard into compliance.


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

raw_content: During the walkthrough, I observed an open water valve recess outside a cottage lacking a protective cover, creating a tripping hazard.  The operation replaced this cover at the time of the inspection.


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

raw_content: During the inspection, I observed three refrigerator thermometers reading in excess of the permitted 40 degrees, and one deep freeze unit lacked a thermometer.

Correction Narrative: On 3/25/24, the operation emailed photo proof of the refrigeration units being replaced or new thermometers installed and showing temperatures in range.    A copy of these pictures can be found in Document Library.  This brings this standard into compliance.


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

raw_content: During the inspection, I observed one child's initial medical exam was completed 24 days past the 30 days from admission date.

Category: Admission, Service Planning, Discharge

Correction Narrative: On 3/27/24, the operation provided an email accounting of their shift in protocol, unify medical appointments under a single person to ensure important deadlines were not missed.  He noted this referenced file predated that protocol shift and this new procedure will prevent recurrence of this issue in the future.  A copy of this email can be found in Document Library.  This brings this standard into compliance.


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

raw_content: During the inspection, I observed that one of the maintenance staff hired on 5/1/23 does not have an initial background upon hire with the facility.

Correction Narrative: Following the inspection, the operation administrator provided me with email confirmation that he entered the staff's background check, and I verified in the system that the check has been entered.  Administrator noted that the staff would not be returning to the operation until background check results were received.


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

raw_content: During the inspection, I observed two beds without protective mattress covers.  The operation replaced the mattress covers during the inspection.


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

raw_content: During the monitoring inspection, one child's medication record was reviewed and observed to be missing the full name of the person who administered the medication.

Correction Narrative: On 9/26/23, the operation emailed proof of medication documentation re-training for the staff responsible for medication administration.  This should mitigate the risk of recidivism and brings the standard into compliance.


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

raw_content: During the monitoring inspection, it was observed that two children's medication record and actual medication count did not match. The medication record reflected there were 4 doses remaining while the package only contained 2 doses and another child's medication record indicated 3 doses remaining but the package contained 4 doses.

Correction Narrative: During follow up inspection, all 6 medication records reviewed showed accurate counts with no issues in documentation.  This standard is now in compliance.


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: During the walkthrough, I observed that one of the fire extinguishers in a resident cabin lacked a tag or documentation denoting when it was last serviced.  The operation replaced the fire extinguisher during the walkthrough with one that was properly tagged.


raw_content: During the inspection, I observed a cottage cabinet with a hole broken through it that staff reported being there over two weeks.  The lights in the laundry room of one cabin were burned out and were replaced by the operation during the walkthrough.

Correction Narrative: on 9/26/23, the operation emailed proof of the repaired cabinet in the form of pictures documenting the repair.  This brings this standard into compliance.


raw_content: During the inspection, I observed a mini fridge in one of the cabins that exhibited a thermometer reading of 50 degrees Fahrenheit.  The operation turned down the temperature in the unit during the inspection to correct the temperature.

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


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

raw_content: In reviewing the documentation and investigation interviews, I observed that the operation failed to report the serious accidental injury of a resident within 24 hours.

Correction Narrative: On 8/14/23, the operation provided a written plan of correction indicating that operation staff would be retrained on reporting procedures and time frames.  It states that all incidents are to be reported to the Residential Director on-call, and then reported to one of two Directors of Residential Living and one of them will report to the Executive Director.  The administrator clarifies in the text that he will inform his staff that the reporting timeframe begins at the time of the incident.  He also indicated that this training would occur on 8/14/23, and the individual that failed to report the incident in a timely manner will be reprimanded with a possible financial penalty depending on the outcome of the Administrative Penalty.  A copy of this plan is stored in RCCR digital storage for this investigation.


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

raw_content: During the investigation inspection, there was a jug of mop solution located under the kitchen sink, unlocked, in the New Lodge Home.


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

raw_content: During the inspection, I observed four mattresses on the floor of loft areas in the cabins.

Correction Narrative: During the inspection, I observed that the cabin mattresses have been fitted with risers that raise the beds off the floor of the loft sleeping areas.


raw_content: During the inspection, I observed two refrigerators without requisite thermometers.

Correction Narrative: During the inspection, I observed that the refrigerator thermometers had been replaced and were functioning properly.


raw_content: During the inspection, I observed a light switch in one cottage with a missing face plate, and a cabinet door in another cottage had a faulty hinge.

Correction Narrative: During the inspection, I observed the light switch and cabinets were repaired and in good condition.


summary: 748.863(a)(3) - Caregiver for child-care or prog. svcs only must have 8 hours EBI training, 4 before counted in ratio, rest in 90 days; 16hrs for treatment svcs

raw_content: In one of six employee records reviewed, the caregiver employee did not receive 16 hours of EBI preservice training.  Only two hours were documented for the employee in the file.

Correction Narrative: The operation provided documentation showing the missing EBI training for the caregiver's file.


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

raw_content: In one of the six employee files read, the record did not reflect the employee receiving annual Normalcy training in the past two years.

Correction Narrative: The operation provided an email detailing measures to ensure each staff member receives Normalcy training annually by providing regularly scheduled opportunities twice a year and requiring all applicable staff to participate.


raw_content: During the walkthrough, I observed holes in the drywall in the bedroom of one lodge and the downstairs bathroom of the second lodge.

Correction Narrative: I observed the locations in where the holes were previously located in the cottages.  The operation has patched the holes and the walls are now in good repair.


summary: 748.685(c)(5) - Caregiver responsibility - ensure continuity of care by sharing information concerning each child with incoming caregivers

raw_content: The purpose of this rule is to protect the health, safety and well being of children in care by ensuring that caregivers are provided and are informed of all the child's needs, medical conditions and any other information of the children they are supervising.

Correction Narrative:
Email received from the agency.
Correction:  The agency we will continue to have the allergies listed on the outside of the child's notebook, written on the initial assessment, verbally communicated to the intake house staff, and a memo will be put in all staff's mailboxes today directing them to communicate to any staff coming into the intake about the child's allergy and communicating to the staff of another house that the resident may visit about the allergy as well.  The memo will be distributed July 14th, 2022.


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

raw_content: A Staff Member was provoking / antagonizing the child in care by raising her voice and saying things such as oh your pissed off, theres the door and your mad at me so why dont you hit me.

Correction Narrative: We will address with our staff in our Monday morning training meetings what is the appropriate way to interact with kids and how to engage with them in a manner that is not provoking.  We will do this over the next two weeks to ensure that we cover all residential staff members.  We also just completed a staff training week last week where we covered a lot of these types of topics as well


summary: 748.1501(a)(1) - Dental care-Children in care must receive dental care initially  according to the requirements in 748.1225

raw_content: (2) out of (6) records reviewed were missing a dental examination. One record indicated that an appointment was rescheduled, however, there was not an appointment scheduled.

Category: Child Care

Correction Narrative: The operation will maintain all dental care as noted by treating doctors. The child that was missing the appointment has a future appointment scheduled.


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

raw_content: In 4 of 4 records reviewed there was not a documented notice given for the child service planning meeting.

Standard Risk Level: Low

Correction Narrative: An email template was provided of the email that will be sent out to parents at least two weeks prior to the service plan being due. The Director of Counseling has set up a schedule on the computer indicating when service plans are due and  reminders to send to families. The Director of Counseling is the sole person in charge of ensuring this happens, so that it only passes through one individual.


summary: 748.3233(b)(2) - Evacuation-Emergency evacuation & relocation diagram must include designated location outside operation where all caregivers & children meet

raw_content: (1) of the (2) homes inspected had emergency evacuation and relocation diagrams that did not include designated location outside of the building. Also, the designated meeting place for weather disaster was not included. This is a separate standard, but all designated meeting areas for emergency evacuation should be included on the diagram.

Correction Narrative: An email was sent with attached diagrams reflecting emergency evacuation routes for all houses with meeting places noted on the diagram.


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

raw_content: A child drank hand sanitizer and had to be taken to the Emergency Room.  Staff failed to report this incident to the hotline.

Correction Narrative: Brooke Lane of Heartlight sent an email stating that they would be upholding standard 748.309, and that they would be reporting all serious incidents according to the standard.


summary: 748.303(a)(11)(A) - Serious Incident-Report to Licensing as soon as aware of a suicide attempt by a child

raw_content: There were two unreported suicide attempts on 3/7 and 3/8/2021.

Category: Reports and Record Keeping

Correction Narrative: New training was done to  re-teach staff What needs to be reported - and what the time frames are.


raw_content: Two cabins were inspected and one bed was missing a mattress protector; and another bed was missing a pillowcase.

Correction Narrative: Pictures were sent of the mattress protectors and bedding on the beds that.


summary: 748.2855(a)(5) - EBI Documentation-Must include the date and time the intervention was administered

raw_content: Six out of the eight emergency behavior interventions records reviewed showed no time of the incident.

Category: Emergency Behavior Intervention

Correction Narrative: New training was done to  re-teach staff how to do restraints, and how to report any restraints.  See digital storage.


summary: 748.2551(f) - EBI Implementation-If child doesn't understand what to do to be released, caregiver re-explains every 15 minutes until child understands or released

raw_content: Two of the eight emergency behavior intervention records reviewed showed that caregivers failed to re-explain every 15 minutes what the child needed to do in order to be released from the intervention.


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

raw_content: The operation failed to report a child in care was taken to the hospital for an allergic reaction to a known nut allergy, that warrant treatment by a medical professional.

Correction Narrative: The operation scheduled a meeting with all regional directors, who are on-call and typically the ones that are making the reports to the hotline number when these types of situation arise, to discuss not only filing in the appropriate time frame, but also communicating in the operation chain of command  effectively so that this type of thing doesn't get missed again.


facility_name: Positive Steps Inc

summary: 748.151(6) - Operational responsibilities -Complying with the liability insurance requirements in this division; and

raw_content: The operation does not have an up-to-date liability insurance policy.

Correction Narrative: The operation was placed on a voluntary suspension to have time to correct standard deficiencies.


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

raw_content: The operation does not have a current health inspection. The operations last health inspection was 2/25/2023.


summary: 748.3061(2) - Gas Inspection-Operation inspected at least once every 24 months from date of last inspection for gas leaks

raw_content: The operation does not have a current gas inspection. The operations last gas inspection was on 2/20/2023.


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

raw_content: The operation does not have an up-to-date fire inspection. The last fire inspection was 4/4/2023.


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

raw_content: There is no licensed Administrator at the operation.


raw_content: During a monitoring inspection it was found the operation does not have an up-to-date liability insurance policy.

Standard Number / Description: 748.151(6) - Operational responsibilities -Complying with the liability insurance requirements in this division; and


raw_content: During a monitoring, it was determined the administrator's license is lapsed.

Standard Number / Description: 748.151(1) - Operational responsibilities - Designate a qualified full-time child-care administrator


raw_content: During the inspection it was found that the operation does not have a current health inspection. The operations last health inspection was 2/25/2023.

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


raw_content: During the inspection it was found that the operation does not have an up to date fire inspection. The last fire inspection was 4/4/2023.

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


raw_content: During the inspection it was found that the operation does not have a current gas inspection. The operations last gas inspection was on 2/20/2023.

Standard Number / Description: 748.3061(2) - Gas Inspection-Operation inspected at least once every 24 months from date of last inspection for gas leaks


Deficiency Narrative: During the inspection it was found that the operation does not have an up to date fire inspection. The last fire inspection was 4/4/2023.


Deficiency Narrative: During the inspection it was found that the operation does not have a current health inspection. The operations last health inspection was 2/25/2023.


summary: 748.4041 - Driver & passengers must follow all laws when driving, including laws on use of child passenger safety seat systems, seat belts & liability insurance

raw_content: The operations vehicle it uses to transport children in care inspection was expired.

Correction Narrative: The operation sent a picture of the up to date vehicle inspection sticker located on the operations vehicle. The operation also sent the following statement: Positive Steps will ensure that the vehicle inspection will be inspected within the annual timeframe.  The operation has not had children in care since April 2023 therefore children in care were not transported in the vehicle with the expired registration.


summary: 748.1009(2) - Child/caregiver ratio-Must employ adequate number of caregivers to meet their responsibilities regarding supervision of children in 748.685

raw_content: The operation did not accompany a child to the hospital or send a staff member to the hospital to accompany a child.

Correction Narrative:
Children have not been placed at the operation since 04/2023.
Positive Steps will maintain compliance with the child-staff ratio to adequately supervise children, ensure children's safety and meet the children's needs.


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

raw_content: Facility could not provide documentation in a timely matter when requested.

Correction Narrative: The operation sent a corrective action plan stating the following: Positive Steps will maintain current, true, accurate, and complete records.  Also, Positive Steps will ensure that all requested documentation will be available for review or submitted in a timely manner.


summary: 748.1693(a)(1) - Nutrition-Provide food of adequate variety, quality, and in sufficient quantity to supply the nutrients needed for proper growth and development

raw_content: The interview with children in care and collaterals corroborated that the children in care were not provided with enough food to eat..

Correction Narrative: An inspection was conducted. Please see inspection number 3974755. The operation has not had children in care since April 2023.


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

raw_content: A child's medication was missing one pill without explanation.

Correction Narrative: I spoke with administrator Yvonne Hawkins who stated the pill that was missing from the child's medication packet had fallen on the floor and was disposed of in the trash. Ms. Hawkins stated if an incident like this occurs again, she will have staff members take a picture of the pill and document the incident. She also stated a replacement pill was called in by the pharmacy and the child will not miss a day without the prescribed medication.


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

raw_content: One child's medication log did not have documentation for the medication being administered within the appropriate time frame.

Correction Narrative: Administrator Yvonne Hawkins stated she will make sure staff are aware that they must document a medication was administered within the appropriate time frame of two hours.


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

raw_content: One of the beds being occupied by a child in care did have a waterproof mattress cover


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

raw_content: Inspector did not receive requested documents in a timely manner. Request were sent July 16 but did not receive the documents till August 14th.


facility_name: HMIH CEDAR CREST, LLC

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

raw_content: A staff member was determined by the background check unit to be ineligible to be at the operation on 1/9/25. The staff worked on 1/11/25.

Correction Narrative: Background check was resubmitted, and staff was provisional as of 1/16/25.


summary: 748.863(a)(3) - Caregiver for child-care or prog. svcs only must have 8 hours EBI training, 4 before counted in ratio, rest in 90 days; 16hrs for treatment svcs

raw_content: A caregiver did not have 16 hours of preservice EBI training within 90 days of being hired.

Correction Narrative: Email from the operation: length of training hours and credit will be standardized across all trainings to meet minimum standards to include trainer's credentials and employee signature. Reflection of this will be shown starting on New Hire 1/27/25 training packets.


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

raw_content: Three of three child files did not have documentation that parents were notified of service plan meeting at least two weeks before the meeting. Two files had documentation that had incorrect dates while the other file had no documentation at all.

Correction Narrative: Email from the operation- this information will be attached to their service plan template.


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

raw_content: Through multiple interviews of staff and children it was determined that staff have been heard using profane and abusive language towards children.

Correction Narrative: Two staff and two children were interviewed.  It was reported that no profane or abusive language is being used.  The operation is providing ongoing training for appropriate discipline.


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 left unsupervised in a hallway by themselves. The child accessed a hospital gown and used the strings to tie around their neck. After the child was placed on 1:1 observation, the staff assigned to the child responded to incident involving another child and brought the child on 1:1 to the other child's room and was not providing 1:1 observation.

Correction Narrative: Two staff and two children were interviewed and report when a child is on 1:1 the staff assigned to them cannot and does not engage in any other activities or respond to situations and they remain with their assigned 1:1 child.


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: Six children and three staff who were interviewed report on 7/7/24 three children were placed on 1:1 observation and the rest of the unit was out of ratio.

Correction Narrative: Two children and two staff were interviewed and report the operation is maintaining ratio. Additionally, a walkthrough of one of the units was conducted and was in ratio.


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

raw_content: Three of three children's files did not have documentation of dental exams being completed within the last year. No dental had been scheduled for the children.

Correction Narrative: The operation will begin utilizing a mobile dentist for appointments to be made if records cannot be obtained and children are overdue for dental exams.


summary: 748.930(a)(2) - Caregivers at operations with 25 or more children or 30% or more of their population receiving treatment services must have 50hrs annual training

raw_content: It could not be verified that a staff had 50 hours of annual training for 2023. The staff's onling training showed less than 15 hours and other trainings did not have the number of hours.

Correction Narrative: Human resources is aware that training hours need to be added to certificates and also now understand some training hours may roll over from the previous year, if staff had more than 50 hours.


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

raw_content: In a serious incident report reviewed it was noted a child swallowed a zipper and was taken to the emergency room for X-rays. This was not reported to RCCR.

Correction Narrative: Incident report binders have been placed on each RTC unit containing the phone number and website for reporting abuse/neglect and all required serious incidents. Requirements for reporting serious incidents are contained in the binders for reference. These binders are accessible to all staff.


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

raw_content: Staff sitting in the hallway observing children in their bedrooms did not notice when one child went into another child's room, where the two children appeared to have engaged in inappropriate physical contact with each other. This was observed by a different staff member.

Correction Narrative: The staff member involved has been re-trained concerning supervision requirements and has also been moved to work days.


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

raw_content: Staff did not intervene appropriately on children who were playing a potentially dangerous game of seeing how long they could hold their hands in fire ant beds. Multiple interviews indicate staff saw what the children were doing and redirected but did not continue to redirect or prevent children from gaining access to other ant beds. Two child had serious reactions to the ant bites and had to be taken to the emergency room.

Correction Narrative: Staff working on the unit have been re-trained concerning supervision requirements.


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

raw_content: A child in care attempted suicide on 4/24/24 and this was not reported to Residential Childcare Regulation until 4/28/24.

Correction Narrative: Incident report binders have been placed on each RTC unit containing the contact phone number and website to file reports. These are accessible to all employees. Minimum Standard requirements for reporting serious incidents are contained in the binders for reference and verification of reporting requirements.


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

raw_content: Observation logs for several children note each child was inside the unit and calm during the same time the children were involved in an altercation outside the unit. Staff who report being inside the unit were completing observation logs on children who were reported to be outside the unit. A staff who says they were outside the unit, handling the physical altercation between children documented and initialed off on a child's observation log that the child was calm and inside and the same time the child was reportedly involved in an altercation outside the unit.

Correction Narrative: Through interviews of staff observation logs are maintained in real time. A walk through showed observation logs were current and accurate. When an incident occurs leadership staff compare the incident report to observation logs and address discrepancies. Files will be audited monthly to ensure accuracy.


raw_content: Two out of two staff interviewed regarding ratio report ratio was not being maintained during an incident as there were more than 10 children outside with two staff. One of two children interviewed regarding ratio report ratio was not being maintained during an incident as there were more than ten children outside with two staff.

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

Correction Narrative: A walk through of the operation was conducted on 5/21/24 and ratio was being maintained. Through interviews it was determined staff  understand ratio requirements and who to contact if ratio is in question. Additionally there are patient assignment sheets and leadership staff conduct walk throughs to ensure ratio is maintained.


raw_content: Multiple staff and children in care indicated that a staff used profane language at a child in care.

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

Correction Narrative: Two staff and two children were interviewed and report no staff are yelling or using derogatory language with children. Staff have had training regarding prudent judgment, zero tolerance, child's rights, caregiver responsibilities to address maintaining professionalism and therapuetic boundaries with children in care.


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

raw_content: A staff member admitted to threatening pulling the hair of a child in care.

Correction Narrative: Two children and two staff were interviewed and report no staff have been threatening children. Staff were trained on prudent judgment, child's rights, caregiver responsibilities to address staff not threatening children and maintaining professional and therapeutic boundaries. Additionally, the staff involved was terminated.


summary: 748.1101(b)(1)(A) - Children's rights-rights to good care and treatment that meets the child's needs in the most family-like setting possible

raw_content: During the course of interviewing children four of five indicated that staff is using derogatory language that is belittling to children in care. The children also indicated that staff curse in general.

Correction Narrative: Two staff and two children were interviewed and report no staff are yelling or using derogatory language with children. Staff have had training regarding prudent judgment, zero tolerance, child's rights, caregiver responsibilities to address maintaining professionalism and therapeutic boundaries with children in care.


raw_content: 4 out of 4 interviews noted there were only 2 staff in ratio for 24 children the morning of 2.15.24.

Correction Narrative: 4 children and 3 staff were interviewed regarding ratio. All report ratio has improved. A walk through of the units was conducted and ratio was maintained.


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

raw_content: 3 children and 3 staff have received undercooked and/or molded items served in the cafeteria.

Correction Narrative: 4 children and 5 staff were interviewed. No one reported thinking food was undercooked or expired. Additionally a new dietary manager was hired who is coordinating a system to ensure no expired food is used and foods are checked for temperature prior to being served.


raw_content: During the walk through of Unit I 24 children were observed with 3 staff. Two children were in the hall out of the sight of staff.

Correction Narrative: A walk through of the units was conducted an ratio was being maintained. Additionally 3 staff were interviewed and report ratio has improved.


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

raw_content: A child, admitted on 1.26.24, did not receive their ADHD medication until 2.6.24. While the medication was pending review on 1.26.24, it was approved by the psychiatrist on 1.27.24.

Correction Narrative: The medication was delayed from the time of psychiatrist approval until consent from the child's parent was obtained. The operation has re-educated nurses on documenting all attempts to contact parents for consent of medications.


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

raw_content: 2 entries on the MARs log for 1 child did not have the actual medication error documented.

Correction Narrative: A nurse was interviewed and was able to discuss requirements for what must be documented when there is a medication error.


raw_content: During interviews with caregivers and children it was evident the operation had not maintained the required 1:5 ratio.

Correction Narrative: Three children and two caregivers were interviewed regarding ratio, there was no evidence to indicate ratio was not being met. A walkthrough was conducted and staff to child ratio was compliant.


summary: 748.125(g)(2)(B) - You must not leave the child alone until a mental health professional assesses the child, in the event of a suicide attempt.

raw_content: After reviewing the information it was determined a child rose to the level of Suicide Attempt, but did not get assessed by a medical person that falls under the definition of a Mental Health Specialist.

Correction Narrative: Two staff were interviewed and report taking training again regarding suicide postvention and understand a child cannot be left alone until assessed by a mental health specialist.


raw_content: During the course of the investigation it was found one of the victim's and another child were in an altercation and the other child was choked. This was not reported to Licensing and was found during the investigation process.

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

Correction Narrative: Nurses underwent training regarding serious incident reporting. Expectations for what should be reported was discussed with risk manager and aplan to develop consistency was discussed.


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

raw_content: Through interviews of staff and children it was determined that a caregiver did not use a permitted type of emergency behavior intervention when they had their legs wrapped around a child's waist.

Correction Narrative: Two staff and two children were interviewed. All report staff are restraining appropriately. EBI trainer was interviewed and confirmed re-training the staff involved in this incident. Additionally, the staff involved has not been working on RTC units and works with adult acute patients now.


raw_content: Two children were able to gain entry into a bathroom that is supposed to remain locked and only have one child at a time in there. While in the bathroom the two children had inappropriate contact with each other.

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

Correction Narrative: Two staff and two children were interviewed and report staff supervise appropriate. Staff report understanding of remaining nearby until one child is done using the restroom before allowing another child in the restroom. Staff have been provided training regarding supervision of children.


summary: 748.303(a)(3)(A) - Serious Incident-Report to Licensing as soon as aware of allegations or indications of abuse, neglect, or exploitation of a child

raw_content: During review of operation documentation, a nurse's note was reviewed regarding an incident where a child was hit by a staff member on 1/17/24. This was not reported by the operation until 1/20/24. The staff that witnessed the incident did not report at all.

Correction Narrative: Nurses have undergone training concerning serious incidences that need to be reported and what those time frames are. 3 staff were interviewed and took Zero Tolerance training which includes reporting abuse and/or neglect to a child.


raw_content: It was observed by staff that another staff struck a child in care after that child hit that staff.

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

Correction Narrative: Two staff and two children were interview and report they have not witnessed staff hitting children. Staff have taken zero tolerance training and training on reporting abuse and or neglect. Additionally the staff involved in this incident has been terminated.


summary: 748.753(d)(1) - Pre-Employment-You must document in the employee record each references name, relation, date completed, info obtained and name of interviewer.

raw_content: In one of the employee files reviewed, references were not documented to verify or discuss the applicant's suitability to work with or around children.

Category: Personnel

Correction Narrative: The operation uses a third party agency to verify references and employment. In the event this third party agency is unable to complete the reference, HR will.


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

raw_content: It was found two staff got into a verbal altercation waking children up in the middle of the night due to yelling and cussing.

Correction Narrative: 4 children and 3 staff were interviewed and no one reported hearing staff arguing. Additionally one of the staff involved is no longer employed and the other was moved to another unit.


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: Statements from children in care and staff members stated that the operation only had one staff member for twelve residents.

Correction Narrative: A walk through of the units was conducted an ratio was being maintained. Additionally, 3 staff were interviewed, and report ratio has improved.


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

raw_content: Statements provided by both children in care and staff members stated that profane language is being used and directed at children in care.

Correction Narrative: 4 children and 3 staff were interviewed and note that staff don't curse. Additionally staff have take Zero Tolerance training.


raw_content: A caregiver did not demonstrate prudent judgment or self-control when they cursed around a child, made intimating comments and stood in front of a child in an intimidating way.

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: Two children and three staff were interviewed and it was assessed that staff have not been observed psoturing up to children in an intimidating wat or making any inappropriate or threatening comments to children. Additionally, the staff involved received training on zero tolerance and prudent judgment.


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

raw_content: Throughout the course of the investigation five children and four staff interviewed stated that a staff member purposely spilled iced coffee on a child in care.

Correction Narrative: 3 staff were interviewed and reported taking Sero Tolerance training regarding how to treat children in care. Additionally the staff involved in this incident is no longer employed.


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

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

Correction Narrative: Two children and two staff were interviewed and report no concerns for staff hitting children. Staff were re-trained on zero tolerance, child's rights, prudent judgment, and caregiver responsibilities. Additionally, the staff involved was terminated.


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

raw_content: Two children in care were put on a safety plan that included them to remain 10ft apart at all times. It was determined that this was not implemented at all times.


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

raw_content: While reviewing documentation it was noted that a child's psych eval was signed and dated prior to the child presenting at the operation and not the date that the evaluation occurred.


raw_content: During interviews it was evident the operation had not maintained the required 1:5 ratio. Ratios documented were 4:31 with a child on 1 to 1 supervision and 2:32 with a child on 1 to 1 supervision.

Correction Narrative: A statement was received by the Administrator on 2.13.24. It explained the Patient Care Assignment Sheet would be implemented by 3.1.24. This will document what staff are assigned to what children.


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

raw_content: There was inappropriate graffiti on multiple bathroom walls in one of the units.

Correction Narrative: A walk through of the units was completed. Walls have been repainted and the majority of the graffiti is gone. The There was writing on a few walls and noted to the operation to cover up.


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

raw_content: A child in care had a suicide attempt on 9/30/23. This was not reported until 10/3/23.


raw_content: A child in care with a history of inappropriate boundaries was able to gain access to another child's room and acted out on that child. It was during a time when the hallway was not monitored by staff.

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

Correction Narrative: Staff have been retrained regarding approproate supervision practices. Staff on provisional are not left unsupervised and are no longer lead staff.


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

raw_content: Information gathered during the course of the investigation determined a child was restrained in order to get them to comply in two separate incidents.

Correction Narrative: Met with administrator and risk director and discussed that staff have been informed not to implement a child in order to get them to comply; however in this case the child was trying to go over a fence that leads to a busy highway.


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

raw_content: In Reviewing the Service Plan and Admission Assessment several required items were determined to be missing. Some of the items included Safety Plan for High Risk Behaviors, Life Skills for children, Supervision, Family Information, Manging Conservator information, and Discipline.

Correction Narrative: Met with risk director who showed where the admission documentation information is in the child's file.


summary: 748.311(9) - Serious Incident Documentation-Includes treating licensed health-care professional's name, findings, and treatment, if any

raw_content: In reviewing the Serious Incident Reports from both incidents items were found to be missing such as treating doctor, names of police officer, names of child witnesses and how to identify them, complete information of staff involved.

Correction Narrative: Met with risk director who showed that they now have folders for each serious incident that is reported and this folder includes police report and business card for officer responding if applicable and medical documentation showing treating doctor's name.


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

raw_content: Two of two child files reviewed did not have results of past dental exams that had been done. There is no documentation showing a dental exam had been completed within required time frames.

Correction Narrative: RTC therapists will be trained on requirement to obtain documentation on dental visits. Form will be added to the admission packet having parent verifying that their child has seen a dentist in the past year.


summary: 748.1205(a)(15) - Admission Documentation-Includes a copy of the placement agreement, if applicable.

raw_content: Two of two child files reviewed did not have a placement agreement.

Correction Narrative: Placement agreement form is being added to the admission packet.


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

raw_content: The operation has not had a severe weather drill since March 18, 2022.

Correction Narrative: Severe weather drills have been scheduled out for the operation for the next two years. December drills will cover winter weather and May will cover tornadoes/flooding.


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

raw_content: A child in care was injected with Toradol 3 times in a 3 day span without their parent being notified they were being administered the medication. The operation noted the medication was covered by the "Consent for Emergency Medical Treatment/ Advance Directive" form, however, the medication was administered 2 days after the child initially began feeling chest pains and shortness of pain.

Correction Narrative: A follow up inspection was conducted. The operation has a medical consent form on the unit for nurses to fill out and utilize. This form is in an incident reporting binder.


raw_content: A staff member did not demonstrate prudent judgment when they allowed a child in care to use their personal phone to access social media platforms. Additionally the staff used social media while working. The staff brought fast food to a child in care without prior approval to do so and ignored the appearance of favoritism to one specific child in care.


raw_content: Through interviews it was determined that a staff member did engage in inappropriate contact with a child in care in such a way that meets Texas Family Code and Texas Administrative Code definitions of abuse.


raw_content: A child in care was not free from abuse when a staff member pulled the child to the ground by their hair.

Correction Narrative: The staff involved is no longer working on the residential treatment center units and is being retrained in de-escalation and emergency behavior intervention.


raw_content: Through interviews it was determined five children in care were able to assault another child in care due to a lack of supervision by caregivers. The child that was assaulted sustained serious injuries.


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

raw_content: Through interviews it was determined that appropriate ratio was not being maintained when one staff was left alone on one side of the unit with 12 children.


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

raw_content: Caregivers were unaware that a child in care, who had history of suicidal gestures, went into the restroom until the door was opened for another child. The child was found unresponsive with clothing around their neck. Additionally two children were placed on 1:1 precaution and one caregiver was observed to be watching both children, which would not meet the 1:1 criteria.

Correction Narrative: Staff have received training regarding appropriate supervision and ensuring caregivers are aware of children's on going activities.


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: There were multiple reports that ratio was not being maintained on a day when a child was found unresponsive with clothing around their neck. It was reported there was at least one child on 1:1 supervision, leaving 4 staff to supervise the remaining 28 children.

Correction Narrative: Inspection was conducted on 1/18 and 1/19. The units were in ratio.


raw_content: Through interviews with staff and children it was determined unit 1 was out of ratio on the day an incident between two children occurred. Multiple reports were that one staff was supervising 12 children.


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

raw_content: Two children were able to engage in consensual inappropriate sexual contact with each other. One of the children was on a side of the unit they were not assigned to and was in another child's bedroom, which is not allowed. Both children had history of inappropriate  boundaries and due to a lack of being appropriately supervised, they were able to engage in inappropriate behavior.


raw_content:
It was discovered that there were only two caregivers with 14 children. This left the group out of ratio.

During a second walkthrough it was found that 1 of 3 units were out of ratio.  There were 24 children with 3 caregivers. Two nurses were on the unit found to be working in the nurse station at the time.

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

Correction Narrative: Compliance at follow up inspection on July 3, 2023.


raw_content: It was determined that two children in care were missing from the operation for about 15 minutes before staff realized they were gone. It was also determined that staff did not realize a door that was supposed to be secured was left opened and children were able to leave the building.

Correction Narrative:
The operation trained their staff regarding the how the magnetic doors operate.

Additionally an inspection was conducted on 11/8/23 and observed that the operation has covered more areas of their fences with mesh to reduce a child's ability to climb over the fence.


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

raw_content: Documentation was requested in person, through phone call, and through email over multiple times throughout this investigation and two other investigations.

Correction Narrative: A discussion was held over the phone with the administrator and director of risk management. They understood the reason for the citation. It was discussed and recommended the director of risk management ask for help or delegate some of the tasks in order to meet compliance. An assistant for the risk manager has since been hired.


raw_content: Three children in care who were on restriction got out of the locked home and locked fence and ran away.  None of the staff interviewed could say who was responsible for the children involved in the incident.

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


raw_content: A child in care was restrained to keep them from going out of a fence.

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

Correction Narrative: An email was received on 7/27 stating the operation will provide additional training on EBI to direct care staff working on the RTC units.  All staff will be trained in Handle with Care. This course will train all staff on the importance of only using physical restraint as a last resort to prevent imminent risk to the child.  This will be completed no later than 8/31/23.  An inspection was also made on 08/03/23 and the operation is working on completing this at this time.


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

raw_content: Two children's service plans did not have any information regarding supervision requirements.

Correction Narrative: An email was received on 7/27 stating the operation will ensure all supervision; observations and precaution will be documented on the child's initial service plan. DCS will review 100% of service plans to ensure compliance.  An inspection was also made on 08/03/23 and the operation is working on completing this at this time.


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

raw_content: The log was requested 10 days after the runaway, the 5/27/2023 runs were not documented on the log.

Correction Narrative: An email was received on 7/27 stating the operation will ensure all unauthorized absences are documented on the log in a timely manner.  Risk management will review daily to ensure compliance.


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

raw_content: In reviewing the Serious Incident Reports, items were found to be missing; names of all staff involved and names of all witnesses (outside of children directly involved).

Correction Narrative: An email was received on 7/27 stating the operation will ensure all information is included on the serious incident reports.  These reports will be reviewed daily by risk management to ensure compliance.


raw_content: One of the units had 28 children on the unit. One child required 1:1 supervision. For a period of time there were 3 other staff to supervise the remaining 27 children.


raw_content: There's sufficient evidence to show that staff members were on their phones while counted in ratio and supervising children.


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: It was observed that a caregiver restrained a child in care without an emergency situation occuring and did not attempt to de-escaltate.


raw_content: It was discovered that there were only two caregivers with 14 children. This left the group out of ratio.


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

raw_content: The operation has had a new CEO since April 2023 that would need to be added as a new controlling person. As of 5/18/23 this person still was not added as a controlling person.

Category: Organization and Administration


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

raw_content: The administrator of record is not a full time employee of the operation.


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

raw_content: It was noted there were several pillows being used by children that did not have pillow cases. The pillows had vinyl coverings that were ripped. Several beds did not have sheets.


summary: 748.303(a)(5)(A) - Serious Incident-Report to Licensing soon as aware of an incident of sexual abuse of a child against another child

raw_content: An incident report reviewed showed an incident was documented on 5/7/23 that two children were involved in non consensual sexual activity and this was not reported to Licensing.


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

raw_content: The operation did not maintain true and accurate records as staff training records showed staff did 6 days of orientation in 2 days or less, that staff did 40 hours of observation in one day, staff signed that they did 40 hours of observation but no form was filled out, and training documentation noted staff did CPI training on 2/27/23 but the CPI card notes the training being done on 2/28/23.


raw_content: Through interviews of staff and children it was determined the residential treatment center units (1, 2, and 5) are frequentlly out of ratio, with times where one staff is supervising 20 children.

Category: Child/Caregiver Ratios


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

raw_content: By several caregiver's own admission, it was stated that administrative personnel have breached this standard by sending staff from cottage to cottage while under-staffed to create the illusion they are in ratio when Licensing personnel are on the Operation's premises.


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

raw_content: Based on the staffing schedule and interviews, there were at least 6 times that unqualified caregivers were placed in ratio with the children.

Correction Narrative: Staff involved in this investigation have had the required training. Human resources and administration is working on a system to ensure training is kept up to date.


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

raw_content:
At least 2 caregivers did not have annual trauma informed care training.
Refer to TIC annual training as well, 748.930(b)(3).


summary: 748.881(6) - General pre-service training curriculum-Includes trauma informed care

raw_content:
At least 3 caregivers did not have their pre-service training completed for trauma informed care.
Refer to pre-service normalcy training as well, 748.748.881(7).


raw_content: Based on interviews and the staffing schedule, there were at least 4 occasions where staff were documented to have worked who did not actually work that unit.

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


raw_content: Based on interviews and the staffing schedule, there were at least 3 times a unit was out of ratio due to not having enough workers in the unit.


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

raw_content: A current staff member providing direct care services did not have an active background check. The background check was inactivated on 4.20.23.

Correction Narrative: The staff's background check was re-submitted on 5/16/23.


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

raw_content: A caregiver did not consider permitted types of emergency behavior intervention when they pushed a child to stop them from trying to fight another child. The child was pushed into another child, who fell and hit their head.


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

raw_content: It was determined through interviews that a staff member did push a child, making the child fall and hit their head. It was determined by DFPS this meets to definition for abuse.


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

raw_content: Staff were not aware and accountable of a child's activities when the child was able to obtain a razor and cut themselves seriously enough to where the child required medical attention and had stitches for the injury.

Correction Narrative: An inspection was conducted and noted that staff were in ratio and appropriately supervising children on the unit. Additionally, the operation has begun to provide training to staff on awareness and accountability of children's activity to ensure the safety and well being of children.


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

raw_content: Through interviews of children and staff it was determined when an incident occurred on 4/4/23 the unit was not in ratio. There were 30 children on the unit and only 4 direct care staff could be confirmed to be working when the incident occurred.

Correction Narrative: An inspection was conducted and a walk through of the units was conducted. All units were within ratio during the walk through. Administration staff are meeting daily Monday- Friday three times a day to ensure each unit is staffed appropriately. Leadership conducts rounds at nights and on weekends to ensure staffing is maintained after hours.


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

raw_content: A child's service plan did not have specific information about the level of supervision the child would have at the operation.

Correction Narrative: An inspection was conducted and inspector was informed training is being conducted on service planning requirements to identify procedures for including supervision levels for the children.


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: Rubbing alcohol was not stored in a way that was inaccessible to children in care. A child in care was able to obtain access to the bottle. Several children then ingested the rubbing alcohol. One of the children became sick and required medical attention.


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

raw_content: Staff did not demonstrate prudent judgment or self control when they threw a binder on to the ground and cornered a child for a negative comment the child made.


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

raw_content: A staff member used profane, threatening language to a child in care after a child used inappropriate language.


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

raw_content: Through interviews of staff and children it was determined that during a physical altercation between children at least one, possibly two staff responding to the incident did not assist in intervening on the children fighting. One of the children involved sustained multiple injuries including bruising and swelling to their face.


summary: 748.303(a)(3)(A) - Serious Incident-Report to Licensing as soon as aware of allegations or indications of abuse, neglect, or exploitation of a child

raw_content: On the morning of 3/11/23, children in care reported allegations of sexual abuse of by a caregiver. This was not reported to Licensing until 3/13/23. A report made by one of the administrative staff did not include sufficient details of the abuse to be referred to the appropriate investigative program.


raw_content: During the course of the investigation it was determined a staff member encouraged children in care to show staff their private parts and requested that the children engage in inappropriate sexual activity. Additionally, the staff was observed touching themselves inappropriately.


raw_content: Through interviews it was determined a staff member did not demonstrate prudent judgment when they violated professional boundaries between children in care and caregivers. Staff made promises to children in care of drugs, money, phones, jewelry, and marriage. Additionally, the staff promised to take the children out of the operation.


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

raw_content: 4 of the 4 child files reviewed did not have documentation that a vision or hearing screening was conducted.

Correction Narrative: The operation emailed vision and hearing screenings that have been completed since this deficiency.


summary: 748.2605(a)(2) - Personal Restraints Prohibited-Restraints that obstruct child's airway

raw_content: Through interviews of children and staff it was determined a child's sweatshirt was pulled over a child's face/mouth during the course of a restraint.


raw_content: Staff did not exercise prudent judgment when having children in care clean up another child's excrement as incentive for those children to be able to go on an outing.


raw_content: It was determined a child in care was neglectfully supervised at the operation when they were able to obtain and ingest several different medications, that required the child to be hospitalized.


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

raw_content: Medication was not kept inaccessible other than employees responsible for storing the medication, as a child was able to obtain 6 bottles of medication and ingested an unknown amount of medication, requiring that child to be hospitalized.


raw_content: During the course of this investigation through interviews of children and staff it was determined that some staff did not demonstrate prudent judgment or self control when they got mad, yelled, and punched a wall or meal cart. Additionally, another staff member has made threatening comments to children in care which does not demonstrate prudent judgment.

Correction Narrative: Email from the operation states re-training/re-education will be provided to RTC staff members to ensure all assigned duties are being completed, as outlined by position. This will also include details on proper de-escalation techniques to be utilized within the patient population. This will be completed by 3/31/23.


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

raw_content: During the course of the investigation through interviews with children and staff it was determined staff members are making belittling remarks to children such as telling them to shut up, calling them bullies, saying their hair is "nappy", saying children are annoying, that children stink, and commenting that children have not "washed between their legs."

Correction Narrative: Email from the operation states re-training/re-education will be provided to all RTC staff members to ensure all patients rights are being met and respected, as outlined within the standard. The training will be completed by 3/31/23.