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

raw_content: Three medication records in the provided logs were missing the strength of the prescribed medications.

Correction Narrative:
Inspector conducted an in person follow up from Program Director on 3/11/25. Interviewed two children in care regarding medical care and medication given at the operation. Compliance Plan stated the following: To ensure compliance and provide the highest quality of care to the children in our facility, Respite Care of San Antonio has implemented several preventative measures to guarantee timely and proper medical care. To ensure accuracy in medication administration records (MARs), we have submitted corrections related to allergies, diagnoses, and the reasons for medication being given to  Pharmacy. This ensures prescription information, diagnoses and allergies are properly printed on our MARs. Moving forward, we will print all MAR sheets when new medications are prescribed, with the exception of newly admitted children that arrive at our facility with prescribed medications that need to be given. This eliminates the need for handwritten entries and reduces the risk of missing information.

Medication administrators are always encouraged to reach out to the medical liaison, UT Health, quality improvement specialist, or program director if any discrepancies are found on the MAR before administering medication. This ensures accuracy, children's safety, and compliance with proper procedures.


state: TX

facility_name: Davidson Respite House

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

raw_content: Medical ca/treatment for a child was delayed, allowing the condition to worsen and cause pain to the child.

Category: Individual Standards Evaluated

Standard Risk Level: High

Corrected at Inspection: No

Correction Narrative: Interviewed two children in care regarding medical care and medication given at the operation. Compliance Plan stated the following: We are ensuring compliance with this issue by continuing to maintain open communication with our UT Health providers through the red medical communication binder. This binder is utilized by supervisors and staff to communicate any medical concerns they have for the children. Additionally, all staff and supervisors are required to report any illness or injury to a child within 24 hours directly to the quality improvement specialist, medical liaison, or program director.


summary: 748.1531(b)(2) - Medical Care-Written record of each medical examination must include the follow-up treatment recommended and any appointments scheduled

raw_content: The Follow Up section of the provided Form K-905-2403 for the Clinic Visit on 1/28/2025 was not completed.

Standard Risk Level: Medium

Correction Narrative: Interviewed two children in care regarding medical care and medication given at the operation. Compliance Plan stated the following: Operation staff will comply with this issue by having the medical liaison review all K905-2403 documentation after medical appointments. Additionally, the after-visit summary will be attached to the documentation when available, ensuring that all follow-up information is effectively communicated. This process guarantees that all required information is completed and that follow-up instructions are clearly outlined, allowing for timely and accurate care for the children in our facility.


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

raw_content: Child in care was left unattended on a changing table, which resulted in the child falling of the changing table to the ground.

Correction Narrative:
Email was sent to Inspector on 12/3/24 from Treatment Director Storm Rivas with the following information regarding deficiency and technical assistance given: To ensure compliance, as well as to provide the highest quality of care possible to the children within our facility, Respite Care of San Antonio has implemented several preventative measures to ensure adequate supervision is always maintained. All staff member(s) involved in this deficiency will also undergo mandatory retraining on RCSA's supervision policies. This is non-negotiable and must be completed within 14 days of assignment. Failure to do so may result in progressive discipline or removal from the schedule.

To ensure compliance, as well as to provide the highest quality of care possible to the children within our facility, Respite Care of San Antonio has implemented several preventative measures to ensure adequate supervision is always maintained. All staff member(s) involved in this deficiency will also undergo mandatory retraining on RCSA's supervision policies. This is non-negotiable and must be completed within 14 days of assignment. Failure to do so may result in progressive discipline or removal from the schedule. As a reminder, all caregivers are required to maintain line of sight supervision during any instance that child is on an elevated surface. These surfaces include but are not limited to changing tables, playground equipment, or any other surface that a fall could reasonably cause injury from that height. All staff members are also reminded to utilize proper safety straps while using changing tables or playground equipment. Failure to do so may result in progressive disciplinary action.

Remember, staff members are encouraged to communicate with one another to ensure children are adequately supervised at all times. There may be instances in which a staff member is requested by their supervisor or colleague to complete an assignment or task that could result in a lapse in supervision. Should this occur, that staff member is encouraged to maintain supervision regardless of the request. No assignment within the facility is more important than ensuring the safety of our children. No supervisor or colleague should also make a request that could hinder the supervision of children knowingly. These instances serve to further exhibit the importance of effective communication when caring for our children. For any questions, please contact the treatment director or quality improvement specialist directly.


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

raw_content: A child's preliminary service plan did not include her immediate needs.

Standard Risk Level: Medium Low

Correction Narrative: RCCR Inspector received email from Treatment Director Storm Rivas on 10/23/24 to inform that on 9/25/24 the RCSA Administration made a permanent change to the Preliminary Service Plan Structure to more accurately represent the needs of our children. Unfortunately, the child for whom the citation was given arrived at our facility on 9/11/24 and was not represented in the change. As of 9/25/24, RCSA case managers have been instructed to utilize the new template that was created based off the requirements present within the Health and Human Service Commissions Minimum Standards. All residents placed after 9/25/24 will have this change reflected within their service plan. A copy of the original and revised template will be provided along with this plan.


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

raw_content: Multiple staff were aware a child had medication in their room and did not confiscate it.

Correction Narrative:
RCCR Inspector received email from Treatment Director Storm Rivas on 10/23/24 to inform that on 10/1/24 a CAP was implemented by RCSA administration stating the following. This Plan was posted within the home and signed off on by caregivers as an acknowledgment.

It is the expectation within Respite Care of San Antonio (RCSA) that all medication be appropriately stored within a locked container only accessible to staff given permission to administer medication. No child is permitted to possess any medication within their own room, on their person, or in any capacity unless otherwise instructed by the Treatment Director, LCCA, Or Designee. All medications, including OTC medication, must be stored within the Davidson Respite House (DRH), double locked behind the Medication Closet and the Medication Cart. There is no exception to this rule. Should a staff member become aware of any violations to this procedure, they are to immediately report the violation to the Quality Improvement Specialist, Treatment Director, LCCA, or Designee. Failure to do so, or failure to immediately remedy the violation will result in disciplinary action.

A follow up inspection was done at Davidson Respite House on 10/15/24 and a walk through was conducted at the Najim House with Treatment Director. There were no concerns during the walk through. Medication closet and cart with all medications was locked and secured at Davidson Respite House.


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

raw_content: A bottle of ibuprofen was found in a child's drawer.

Correction Narrative: Inspector conducted a in person follow up and interviewed two staff supervisors to discuss medication management. A walkthrough was conducted of the Najim House. No concerns were observed.


summary: 748.3271(3) - First Aid Kits-Each one must be in good condition and not have expired medications or supplies

raw_content: First aid ointment inside the vehicle and first aid kit was expired.

Standard Risk Level: Medium High

Correction Narrative: Inspector received compliance information by email from Treatment Director Storm Rivas with the following information: To ensure compliance with this standard, RCSA will implement monthly audits of the First Aid kits. These audits will occur during the first or second Friday of every month, day permitting. The goal is to complete these audits bi-weekly, time allowing. Audits will be completed by the Medical Liaison at a minimum every 30 days. Audits will be documented and tracked via an audit checklist. As of 10/15/24 RCSA will have purchased new and sealed first aid kits to replace those which were out of compliance during the previous monitoring review. As of now, any items causing the existing kits to be considered non-compliant have been removed.


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

raw_content: No documentation of an updated fire inspection was provided during the monitoring inspection. Documentation provided by staff was to an expired inspection.

Correction Narrative: Inspector received compliance from Treatment Director Storm Rivas by email with the following information: Moving Forward, we will be implementing a check in 3 months prior to the renewal date to allow ample time for issues such as the ones we are currently experiencing. This check in will occur 90 days prior to the listed date of renewal on the permit once in hand.


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

raw_content: The address, and relationship of person is missing on the discharge summary of one of the child's file. The medication list, dosage, frequency and reason required information is missing from the documentation. The entire discharge requirement format is missing from a child's file evaluated.

Category: Admission, Service Planning, Discharge

Correction Narrative: Inspector received compliance information by email from Treatment Director Storm Rivas with the following information: RCSA's contracted medical team through the UT Health Wellness 360 Clinic will continue to provide discharge documentation that lists all medical and specialty care, as well as follow ups and the contact information of these providers. Moving forward, as of 10/7/24, RCSA will begin to file a copy of this documentation within the child's file. RCSA will also be completing the DFPS form K-908-2279 titled Placement Summary for all discharges after the effective date. This will be filed within the child's folder and sent to the child's case worker if applicable. The purpose of this form will be to highlight the accomplishments the child achieved while in care as well as to summarize all necessary information that may be beneficial to a new placement.


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

raw_content: Fire extinguishers are not being conducted monthly and reported to be done every three months.

Correction Narrative: Inspector received compliance information from Treatment Director Storm Rivas with the following information: To ensure compliance with this standard, RCSA's maintenance and facilities staff will complete monthly audits of the fire extinguishers in which he will sign off on the present tag to signify his audit. This will occur the first Tuesday-Wednesday of every month during routine HVAC air filter changes in which this individual will also audit the smoke detectors and complete a visual check of the facilities.


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

raw_content:
The operation staff were not aware a resident had not returned to the operation
until it was bought to their attention.

Correction Narrative: Two staff members were interviewed and discussed the compliance plan that was provided and signed by all staff members. The staff discussed they are aware of the plan and shift supervisors will communicate with the staff using an assignment sheet which documents name of child and time and date of child pick up and location. The staff are aware of their expectations and discussed also communicating with higher chain of command if any issues arise. Both staff signed and agreed to the compliance plan and discussed the plan will help ensure staff will know where a child is or where they need to be, and an authorized caregiver is aware as well.


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

raw_content: Video footage confirms a child in care was redirected physically in an inappropriate manner by a staff member, while sweeping. Video footage also shows the inappropriate redirection which caused discomfort to the child.

Correction Narrative:
The corrective action plan was provided to RCCR Inspector via email. The compliance plan stated the following: the expectation is that all staff within Respite Care of San Antonio (RCSA) demonstrate competency, prudent judgment, and self-control in presence of children. This means maintaining a level of mindfulness when completing tasks that directly affect a child or their wellbeing. RCSA will continue its zero-tolerance policy for inappropriate physical direction and continue to self-report any instance that may violate this standard should it arise. RCSA will also continue to utilize present structures to re-emphasize the importance of prudent judgment and self-control when managing our vulnerable population.

RCSA prides itself on our ability to foster positive changes in our youth while instilling the skills necessary for them to progress developmentally. To maintain regulatory compliance, as well as to provide the highest level of care possible, all staff members are trained in SAMA's de-escalation strategies before being alone with our children. Satori Alternatives to Managing Behavior (SAMA) is a state certified and approved curriculum that Respite Care trains in and utilizes. The curriculum includes communication, escorting, basic protection, intermediate protection, advanced protection, and containment. These principles call for the least restrictive action to be implemented as a first resort and that containment should be reserved unless absolutely necessary. During this training, and all subsequent follow up training, it is stressed that staff members must utilize appropriate redirection techniques when managing behaviors. Staff are instructed to utilize the least restrictive intervention necessary to gain the compliance of a child. Staff are also instructed that we are never to utilize physical redirection unless that physical redirection is necessary to maintaining the health or wellbeing of a child in our care. This will continue to be stressed to our personnel during regularly scheduled classes that are to occur within the first 90 days of employment, prior to that staff being counted in the caregiver/ child ratio, and every 6 months thereafter as a refresher course.

Under the guidance of the Treatment Director, all staff within RCSA have also been trained in Working with Intellectual/ Developmental Disabilities as part of their initial preservice requirements. Within this training, the 4 key functions of behavior are referenced, as well as behavioral management techniques that can be completed proactively or retroactively to effectively manage a child's needs. This training consists of nonphysical redirection techniques that are specific to the corresponding function of behavior. This training will continue to be completed as a preservice requirement, but will also be made available upon request, or at the discretion of the treatment team should staff appear to require increased guidance.


raw_content: A staff member entered the bathroom while child was showering.

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

Correction Narrative:
The corrective action plan was provided to Inspector via email as well as discussed in person on 7/25/24 during in person follow up. Davidson Respite staff were notified of the plan, and the supervisors also have the plan posted in their workstation. The plan is as follows: It is the expectation that all staff within Respite Care of San Antonio (RCSA) demonstrate competency, prudent judgment, and self-control in presence of children. This means maintaining a level of mindfulness when completing tasks that directly affect a child or their wellbeing. It is always recommended that RCSA personnel utilize each other as a resource and request guidance whenever necessary to ensure appropriate actions are taken under potentially stressful scenarios. Any action that may feel questionable or potentially harmful to maintaining the health, safety, or wellbeing of a child must be immediately ceased until further guidance can be obtained via the Treatment Director, Quality Assurance Specialist, or designee. It is always recommended that actions outside of normal day to day tasks be consulted upon to limit potentially harmful interactions from taking place. These scenarios include but are not limited to:

	Room Checks
	Retrieval of Property
	Reinforcement or Consequences Not Previously Discussed as a Treatment Team
	Alterations to Established Protocols
	Atypical Requests from the Youth
	Atypical Behaviors from the Youth
	Changes to the Bed Chart
	The Administration of PRN or OTC Medications
	Psychiatric Hospitalizations
	Medical Hospitalizations
	ETC

It is also mandated that any potentially harmful or maladaptive behaviors completed by a resident be reported to the Treatment Director, Quality Assurance Specialist, or designee immediately. This is to begin planning behavioral modifications that meet our criteria for safety and effectiveness.

Caregivers are not permitted to independently manage any of the aforementioned scenarios unless previously instructed by the Treatment Director, Quality Assurance Specialist, or designee; or the scenario presents an active risk to the health, safety, or wellbeing of a resident. Only under those circumstances may a staff act without guidance. Should that occur, at the soonest possible moment, staff must notify the Treatment Director, Quality Assurance Specialist, or designee; and complete a detailed report of the scenario, actions taken, and outcomes in the form of an Incident Report.

During Follow-up inspection 4011888 The compliance plan was discussed with Treatment Director Storm Rivas for follow up 3090326. The compliance plan was also provided to Licensing Representative. Mr. Rivas discussed the expectations of Davidson Respite staff members and signatures would be provided. Personnel will utilize each other as a resource and request guidance from Treatment Director or designee whenever necessary to ensure appropriate actions are taken under potentially stressful scenarios. Two staff discussed they were notified of the plan and discussed the expectations were discussed with all staff members. Also the plan is posted on the wall in the supervisor station. The staff discussed they will ensure the safety and well being of the children in care is priority. The staff discussed they will reach out to staff or shift supervisors when assistance is needed or required and keep open communication to ensure the safety of the child. The staff discussed not being allowed to enter the restroom and shower area unless it is a child who requires or asks for assistance. Two children were interviewed and they did not discuss no issues or concerns for their safety or wellbeing. The children discussed the staff are appropriate and treat them fairly. There were no concerns that the children discussed.


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

raw_content: A prior employee was not inactivated with the operation within the required timeframe.

Correction Narrative: HR will utilize the state website and inactivate a team member withing 7 days of leaving by completing a separation checklist and this process will be documented in the HR policies and procedures manual.


raw_content: The preliminary service does not show immediate needs listed.

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

Correction Narrative: Moving forward, and beginning on 7/5/24, all preliminary service plans will be submitted to the Treatment Director for review prior to their implementation. Should the Plan be implemented, on/or slightly before the 72nd hour, not allowing an opportunity for stringent review. This plan will be subject to revisions by the Treatment Director while continuously notifying DFPS of said revisions. Items that are not made readily available by the 72nd hour of care will be stated within their sections of the 72-hour plan to show verification that Respite Care of San Antonio (RCSA) made a reasonable attempt to gain that information. Information not provided on/or before the 72nd hour of care is at risk of not being present within the 72-hour Service Plan.


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

raw_content: Appropriate staff was no informed of relevant information of children in care.

Correction Narrative:
Beginning on 7/5/24, all active Shift Supervisors will have current shift change policies re-emphasized to them by the Quality Improvement Specialist, ensuring each member is able to effectively articulate the protocols and display a functional understanding of the reason for the implementation. These protocols are as follows:
1. Incoming Shift Supervisors are required to complete a mandatory debrief with the active Shift Supervisor for the purpose of relaying information related to the children in our care. This debrief is to include information related to capacity, changes to the bed chart, children who may be off premises for sanctioned visits or appointments, behavioral issues, resident successes, potential illness or improvement of illness, the administration of OTC or PRN medication, or any other information pertinent to the wellbeing of the children in care.
2.All staff members are encouraged to utilize the GroupMe chat established by RCSA to accurately and effectively relay information to the group. Within this chat, all direct support professionals employed by RCSA to accurately and effectively relay information to the group. The intended purpose being the ability to effectively relay information, request assistance, or seek clarification without the need to jeopardize continuous supervision in the process.


raw_content: Staff member was sleeping on duty.

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

Deficiency Narrative: Staff member was sleeping on duty.

Correction Narrative: Staff was immediately terminated. One child was interviewed and discussed supervision consists of the staff always in the line of sight and in the room with the child during wake and sleep hours. Shift log will be provided. One staff discussed they offer their staff support if they need assistance with the children.


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

raw_content: Staff member was observed physically holding a child inappropriately.

Corrected at Inspection: Yes


summary: 748.115(1) - Discipline policy - Guide caregivers and employees in the methods used for discipline of children

raw_content: A caregiver used inappropriate discipline for a child in care.

Correction Narrative: Operation trained staff on Positive Guidance and Discipline and they have also incorporated this training into their orientation and pre-service training.


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

raw_content: While reviewing the serious incident report the following items were missing from the incident report operation's physical address, telephone number, child's age, gender and date of admission.

Category: Reports and Record Keeping

Correction Narrative: RCCR Inspector received follow-up compliance plan and updated form via email from administrator on 6/22/23.


summary: 748.601 - Treatment Director-Facility providing treatment services to 25 or more children or to more than 30% of children in care must have treatment director

raw_content: During the inspection it was found the operation does not have a treatment director, the operation provides treatment services to almost all children in their care.

Correction Narrative:
Administrator requested extension due hiring process is taking longer than expected.

Treatment Director will start on 08/21/23.

Treatment Director started on 08/22/23. The operation is now in compliance.


raw_content: Staff member used inappropriate redirection technique towards a child in care.

Correction Narrative:
Corrective Action Plan received by email on 3/17/23 is as follows:
Staff Xavier Torres was released on 3/13/2023.
30-minute meetings scheduled with Director of Residential Services every Thursday with Yazmeen Barnes and Camilla Ambros to discuss a TBRI/TIC topic; this will continue for 90 days.
AACOG training, Safety Care for Families will be brought to all team members.
Administrator Ms. Acosta discussed by phone on 4/14/23 the corrective action plan is still in effect.


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

raw_content: During the investigation it was determined that caregivers used prohibited punishment when they yelled at children in care.

Correction Narrative: Follow up was conducted and two caregivers and two children were interviewed.  Compliance plan is in place for the two  employes for 3 months.


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

raw_content: During the investigation it was determined that children were subjected to corporal punishment when staff members pulled them by their arms.

Correction Narrative: Follow up was conducted and two caregivers and two children were interviewed .Compliance plan is in place for the two employes for 3 months.


raw_content: Caregiver was asleep while caring for two children.

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


summary: 748.1763(c) - Infant sleep requirements-Infant may not sleep in prone position with a sleeping adult at any time, including in adult's bed, on a couch, etc

raw_content: Staff was sleeping while holding a infant in care in their arms, in a chair.


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

raw_content: One child's record did not contain daily count for three medications.

Category: Medication

Correction Narrative: Operation has contacted nursing supervisor who provided a screen shot of new pill count field added to patient's medication screen.  Pill count is now visible and available for review upon request/inspection. This information was provided by Administrator.


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

raw_content: Pain/fever medication and two inhaler were not stored in a locked container.   Staff locked medication in a locked container while at inspection.


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

raw_content: Operation admitted they did not report positive COVID-19 as it was overlooked. Positive COVID found on 3/15/21 and intake was received on 3/30/21.

Correction Narrative: Upon receiving results from our testing agency, any positive results received will need to be immediately sent to DFPS partners. Results will need to be sent to the child's case worker, agency licensing representative, as well as, a self-report to the hotline will need to be completed. This protocol will prevent any notifications being misreported to our contracting partners to ensure proper communication. Protocol is effective immediately.


facility_name: Abundance of Joy Home Shelter

raw_content: Staff are allowing children in care to fight without intervening.


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

raw_content: Staff Anthony Baldwin left the operation and went to work for another place not related and came back 2 years later. He had no updated TB test in file since being unemployed by a regulated operation within the previous 12 months.

Correction Narrative: The operation sent the following correction on 5/23/25: The administrator/LCCA will ensure that all rehired staff paperwork and new hire packets are up to date and in compliance with minimum standards.


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

raw_content:
Anthony Baldwin   DOH: 6-17-24
748.505(5)-No Affidavit Form 2912 in file

Category: Personnel

Correction Narrative: The operation sent the following correction on 5/23/25:The administrator/LCCA will be the first point of contact to verify potential client's previous employers in employment history.  The administrative assistant will a spreadsheet with the times and dates of the attempts made by contacting the previous employers.


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

raw_content: Staff Anthony Baldwin No verification in file that employment history or reference checks were completed

Correction Narrative: The operation sent the following correction on 5/23/25:The administrator will ensure that all employee binders are completed, and all documents are in binders.  The executive director will complete a monthly audit once a month to ensure that all binders meet minimum standards requirements.


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: A single caregiver was observed to be present with seven children in care.


raw_content: The operation has an active background check for staff that no longer works for the operation.

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


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

raw_content: Prudent judgement was not demonstrated when children in care were asked to write a reference letter for a caregiver caring for the children.


summary: 748.1349(a)(2) - Initial Service Plan-Give copy or summary of plan to child's parents

raw_content: 2 children's service plans did not have the parent's signature.

Standard Risk Level: Low

Correction Narrative: Sandra Jones as the LCCA and Alice Collins the office assistant will ensure all staff trainings is completed on a monthly basis to ensure AOJ is in compliance.


summary: 748.930(b)(5) - Annual Training- Caregivers must have psychotropic medication training if the caregiver administers psychotropic medication.

raw_content: 1 of 2 direct staff did not have psychotropic medication training.

Correction Narrative: LCCA will monitor all treatment plan along with the PLSP Rashunda Endsley to ensure that all dates and signatures are in compliance for treatment plan.


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

raw_content: Recreational calendars provided for the past 90 days did not outline an indoor & outdoor recreational activity.

Category: Recreation Activities

Correction Narrative: Abundance of Joy Home Shelter will ensure Recreational Activities and other Activities that are appropriate to the needs, interests and abilities of children on a daily basis.  An updated calendar was provided.


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

raw_content: Medication logs reviewed, show no record of medication that was administered.

Correction Narrative: Abundance of Joy Home Shelter will ensure that all medications are signed for on the client's cumulative record immediately after being administered.


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

raw_content: There is no record of practice severe weather drills.

Category: Safety and Emergency Practices

Correction Narrative: Abundance of Joy Home Shelter will practice severe weather drills every 6 months from the date of the last severe weather dill effective immediately and record on Abundance of Joy Home Shelter Severe Weather form.


summary: 748.2461(b)(3) - Short Personal Restraint-Caregiver may not use restraint that obstructs child's airways or impairs child's breathing

raw_content:
During the course of the investigation, a child in care reported not being able to breathe during a restraint involving staff sitting on them. The child reported breathing heavily once released.
Three children interviewed also reported hearing the child say they could not breathe.

Correction Narrative:
Effective Immediately: Staff that were involved in the incident was given a refresher immediately for 4 hours. Moving forward, all training will include demonstrations scenarios to avoid inappropriate
restraint techniques. During the new hire orientation and quarterly trainings, the CPI instructor will real time scenarios during trainings to ensure the direct care staff is comfortable with the technique The CPI instructor will give the direct care staff a certificate upon completion of the training.

On 8/26/24 RCCR conducted in-person interviews with youth in care to the operation EBI techniques.


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

raw_content:
During the course of the investigation, it was reported that staff sat on a childs lungs and belly during a restraint.
Three children interviewed corroborated the child's statement.

Correction Narrative:
Effective Immediately: Staff that were involved in the incident was given a refresher immediately for 4 hours. Moving forward, all training will include demonstrations scenarios to avoid inappropriate restraint techniques. During the new hire orientation and quarterly trainings, the CPI instructor will real time scenarios during trainings to ensure the direct care staff is comfortable with the technique The CPI instructor will give the direct care staff a certificate upon completion of the training.

On 8/26/24 RCCR conducted in-person interviews with youth in care to the operation EBI techniques.


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

raw_content: The operation provided medication logs for the month of November that do not contain consistent information.

Correction Narrative: medication logs at least three days out of the week to identify any patterns or concerns and to ensure the logs are filled out correct and complete by the staff member that will be administering the meds. The direct care staff members will take a refresher course on completing the med logs in its entirety.  The class will be completed by July 16, 2024.


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

raw_content: The operation did not provide a requested medication log after multiple requests.

Correction Narrative: The LCCA and Administrative Assistant will review and track the medication logs at least three days out of the week to identify any patterns or concerns and to ensure the logs are filled out correct and complete by the staff member that will be administering the meds. The direct care staff members will take a refresher course on completing the med logs in its entirety.  The class will be completed by July 16, 2024.


summary: 748.930(a)(1) - Caregivers at operations with less than 25 children or 30% of their population receiving treatment services must have 20hrs annual training

raw_content: Several staff members failed to complete required training prior to being counted in ratio.

Correction Narrative: During the new hire orientation, the LCCA will monitor all trainings to ensure the direct care staff is completing all trainings before they are being counted in the ratio.  The LCCA will have the direct care staff to sign a training roster for all trainings.  The LCCA have created a new training log to include the 40 hours of supervision training before a staff member is allowed to be in the ratio. The supervisor and LCCA will sign off on the training log and a copy will be placed in the direct care staff employee binder.


summary: 748.1347(b) - Initial Service Plan-PLSP must sign and date the plan; If PLSP disagrees with any portion of the plan, he must document issue(s) before signing it

raw_content: One of three youth files reviewed did not contain a signature by the PLSP on the most recent service plan.

Correction Narrative: An email was received from the operation that included an updated service plan for the youth which included the PLSP's signature. A corrective action plan was also included in the email that indicated the operation will be responsible for ensuring all service plans are signed accordingly moving forward.


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

raw_content: One out of four youth files reviewed did not contain all required documentation detailing a youth's discharge.

Correction Narrative: An email was received from the operation that included the missing discharge summary for the youth. A corrective action plan was also included in the email that indicated the operation will be responsible for ensuring they are completed timely moving forward.


summary: 748.931(b)(1) - Annual Training- Administrators, PLSP's, treatment directors and case managers who do not hold a prof. license must have 2 hrs trauma informed care.

raw_content: The administrator did not have all required annual trainings.

Category: Training and Professional Development

Correction Narrative: An email was received from the operation that included verification of the missing training for the administrator. A corrective action plan was also included in the email that indicated the operation will be responsible for ensuring all trainings will be completed timely moving forward.


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

raw_content: Two out of four youth files reviewed did not include known contrindications to restraints for the youth.

Correction Narrative: An email was received from the operation that included the missing information included on an admission assessment for the youth. A corrective action plan was also included in the email that indicated the operation will complete an audit of all current files to include the information and the information has been added to their admission assessment template for future use.


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: One out of three employee files reviewed only contained 34 annual training hours instead of the required 50 hours.

Correction Narrative: An email was received from the operation that included the training log for the employee indicating all required training hours had been completed.


summary: 748.705(b)(1) - Reasonable & prudent parent standard-Must consider the child's age and level of maturity

raw_content: A caregiver took five children in care, ages 9-13, to see a horror movie rated PG-13. Several of these children have history of self-harm and have experienced significant trauma. One childs Conservatorship worker stated that due to her diagnosis, her mindset is much younger than her age.

Correction Narrative: A follow up was completed by interviewing youth in care at school. The youth interviewed indicated they are not allowed to watch scary movies or shows at the operation, and it should be rated PG. They denied watching non-PG shows or movies since the last incident. The interviews can be viewed in Chronology.


summary: 748.3021 - Tools-Dangerous tools & equipment stored so they are inaccessible to children; children use these with caregiver supervision as appropriate

raw_content: During an inspection at the operation, scissors were observed to be accessible in a drawer to youth in care recently after an incident involving scissors occurred with a youth at the operation.

Correction Narrative: Corrected.


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

raw_content: The operation has not entered EBI data in their provider portal for Quarter 4 of 2023.

Correction Narrative: The EBI report was generated in CLASS in which it displayed the missing quarter's information.


summary: 748.125(f)(1) - A PLSP must meet with a child within 24 hours of their return to an operation post hospitalization.

raw_content: A  suicide risk screening was not conducted with a child post returning from the psych hospital.

Correction Narrative: The operation emailed a corrective action plan that indicated the operation's administrative staff will be responsible for ensuring the PLSP who is also the operation's treatment director to conduct a suicide risk screening after a child returns from a behavioral hospital.


summary: 748.681(2) - Caregiver qualifications- HS diploma or GED from program recognized by TEA, TPSAC, other state or documentaion of equivalency from home schooling

raw_content: It was found that 2 out of 3 staff records that there was no high school diploma or GED in the file.

Correction Narrative: A phone call was received on April 20, 2023 from the operation's administrative assistant, Alice Collins, requesting an extension to correct the deficiency so all the corrections can be submitted at the same time due to waiting on an outside party for one of the corrections. An extension of 1 week was granted.  On April 27, 2023, an email was received from the operation which included a copy of 1 staff's missing document for verification along with a CAP. The CAP indicated the other staff has order their transcript and is awaiting its arrival. It also indicated it will be provided once received.


summary: 748.3239(a)(3) - Evacuation-During each fire drill, children must be able to safely exit building to designated meeting place within 3 minutes

raw_content: Four out of four fire/evacuation drills reviewed were not completed within the required three minutes. One out of the four drills reviewed did not indicate the smoke alarm was set off.

Correction Narrative: A phone call was received on April 20, 2023 from the operation's administrative assistant, Alice Collins, requesting an extension to correct the deficiency so all the corrections can be submitted at the same time due to waiting on an outside party for one of the corrections. An extension of 1 week was granted.  On April 27, 2023, an email was received from the operation which included a CAP that indicated the operation will practice the fire drill with the youth in care and admin staff will ensure it is completed within the required 3-minute timeframe and the documentation reflects the alarm is set every time.


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

raw_content: Two out of three child records reviewed did not contain a signed statement to acknowledge the child's rights.

Category: Children's Rights

Correction Narrative: A phone call was received on April 20, 2023 from the operation's administrative assistant, Alice Collins, requesting an extension to correct the deficiency so all the corrections can be submitted at the same time due to waiting on an outside party for one of the corrections. An extension of 1 week was granted.  On April 27, 2023, an email was received from the operation which included a copy of the missing document for verification along with a CAP.


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

raw_content: A serious incident that was reported to the statewide intake hotline by the operation did not have a coinciding report documented at the operation.


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

raw_content: It was found in 2 out of 3 children files reviewed that no child orientation was provided upon admission.

Correction Narrative: A phone call was received on April 20, 2023 from the operation's administrative assistant, Alice Collins, requesting an extension to correct the deficiency so all the corrections can be submitted at the same time due to waiting on an outside party for one of the corrections. An extension of 1 week was granted. On April 27, 2023, an email was received from the operation which included a copy of the missing document for verification along with a CAP.


summary: 745.651(2)(A) - Background Check Validation  Every 3 months each operation, other than a licensed, registered, or listed home, must validate current list

raw_content: The last validation of the employee list in the provider portal was four months ago.

Correction Narrative: A phone call was received from the operation's owner, Donyel Jack, indicating the background checks have been validated in the provider portal. A review was completed as verification.


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

raw_content: One out of seven employee files reviewed did not contain an updated professional licensure as required for their job position nor any record of training completed. Another employee file did not contain a job description.

Correction Narrative: An email was received that included a copy of the treatment director's updated licensure. A phone call was also received from the operation's owner, Donyel Jack, on 9-9-22 in which she stated the missing job description was placed in the staff's file.


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

raw_content: One out of three child files reviewed did not contain a copy of the initial service plan in the file. Two out of three children's files did not contain the most recently updated service plan in the file.

Correction Narrative: An after hour inspection (#3903114) was conducted and the missing service plans were observed.


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

raw_content: The operation has not had an administrator in 90 days.

Correction Narrative: An LCCA has been hired for the operation per a face to face conversation with the operation's owner during an after-hour inspection conducted at the operation.


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

raw_content: There is information to confirm staff use profane language while caring for children.

Correction Narrative: Two out of three youth interviewed stated staff do not use profane language while in the presence of the youth in care.


raw_content: The operation has not had an administrator in 60 days.

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


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

raw_content: A window blind in one of the bedrooms was damaged.

Correction Narrative: A window blind in one of the bedrooms was damaged and has been replaced.


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

Deficiency Narrative: A window blind in one of the bedrooms was damaged.


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

raw_content: One of two bathroom had a broken toilet paper holder. There was an exposed electrical socket in the kitchen dinning area.

Correction Narrative: The deficiency has been corrected by repairs being completed.


raw_content: Two of two bathrooms utilized by children in care did not contain: paper towel or any hand drying agent. One of two bathrooms did not contain toilet paper, One of two bathrooms had a broken vanity exposing piping. One of two bathroom had a broken toilet paper holder. There was an exposed electrical socket in the kitchen dinning area. There was bag of meat in the freezer in a ripped bag exposing the meat. There was a clump of hair in the freezer.

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


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

raw_content: The purpose of this standard is to ensure child care regulation is able to assess records and documentation for accuracy and compliance.


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

raw_content: Two out of two restraints reviewed did not include a notification to the parent.

Category: Emergency Behavior Intervention


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

raw_content: One out of three medication records reviewed had signatures documented/signed prior to administering any medication to children in care.

Correction Narrative: Deficiency corrected


summary: 748.2853(3) - EBI Documentation-Date and time the post discussion took place, if applicable

raw_content: During the inspection, two out of three restraint reports had missing post discussion documentation.


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

raw_content: One out of three medication records reviewed indicate that the medication count was inaccurately logged.


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

raw_content: annual summary log was not given to inspector regarding AWOL as requested

Correction Narrative: An extension has been granted until August 10, 2022. An email was received from the operation's owner, Donyel Jack, which included a corrective action plan indicating all documents will be made readily available to all inspectors on unannounced visits. This is indicated to be ensured by the LCCA. A phone call with Ms. Jack concluded the youth is no longer enrolled at the operation and they will ensure any runaway incidents in the future will be documented on a log as well.


raw_content: No serious incident report was given to inspector regarding AWOL of victim that was called in to licensing

Standard Number / Description: 748.311 - Serious Incident Documentation-Documented in written report

Correction Narrative: An extension has been granted until August 10, 2022. An email was received from the operation's owner, Donyel Jack, which included a corrective action plan indicating all documents will be made readily available to all inspectors on unannounced visits. This is indicated to be ensured by the LCCA. A phone call with Ms. Jack concluded that the employee on duty during the incident no longer works for the operation, and the incident report in fact was given to the inspector investigating.


summary: 748.4657(1)(A) - Annual Training-Every 6 months a caregiver must complete at least 4 hours of training in EBI

raw_content: Reviewing staff training 5 out of 8 staff do not have up to date training for EBI

Correction Narrative: Inspection #3897010 was conducted at the operation in which the employee files were reviewed for up to date training. All employees' EBI training is current.


summary: 748.455(a) - Unauthorized Absence-After a child returns from unauthorized absence, foster parent must conduct debriefing w/child no later than 24 hrs after return

raw_content: No debriefing documentation was given to inspector regarding AWOL of victim

Correction Narrative: An extension has been granted until August 10, 2022. An email was received from the operation's owner, Donyel Jack, which included a corrective action plan indicating all documents will be made readily available to all inspectors on unannounced visits. This is indicated to be ensured by the LCCA. A phone call with Ms. Jack concluded the youth is no longer enrolled at the operation and they will ensure a debriefing is conducted with youth in the future if another runaway occurs.


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

raw_content: There was no documentation sent to inspector regarding EBI being performed on victim and documentation on EBI performed on other children in care who were interviewed

Correction Narrative: An extension has been granted until August 10, 2022. An email was received from the operation's owner, Donyel Jack, which included a corrective action plan indicating all documents will be made readily available to all inspectors on unannounced visits. This is indicated to be ensured by the LCCA. A phone call with Ms. Jack concluded that the employee on duty during the incident no longer works for the operation, and the requested documents were in fact given to the inspector investigating.


summary: 748.2453 - Emergency Behavior Intervention-Only a qualified caregiver may administer emergency behavior intervention, except short personal restraint

raw_content: Due to 5 out of 8 staff EBI records no being current. 5 staff are not qualified to perform EBI.


summary: 748.2851(b) - EBI Follow-Up-Caregivers involved in EBI must conduct a post discussion with child

raw_content: Operation did not send any post EBI documentation regarding the victim or any child in care from the operation


summary: 748.1531(b)(5) - Medical Care-Written record of each medical examination includes any documentation provided by health-care professional who performed exam

raw_content: The operation documents on their incident reports that children are being evaluated by their concierge doctor however there is not always documentation to go along with this and when a document is provided it does not have any official signatures or letterhead and it is unknown who is filling out the document .


raw_content: Staff failed to complete EBI documentation for serious incidents involving children in their care.

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


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: One staff member supervised 6 children in a van on 03/20/2022 when a physical altercation occurred.


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

raw_content: Staff failed to report serious incidents involving children in their care to the hotline.  Incidents involving physical abuse between children were not reported timely.


summary: 748.303(a)(4)(B) - Serious Incident-Report to parents immediately after ensuring the safety of the child.

raw_content: Staff failed to report serious incidents involving children in care to the parents.  Children have been involved in serious incidents requiring medical evaluations after and parents have not been informed within required time frames.


summary: 748.4045 - Safety restraints-only one person may use each child passenger safety seat system or safety belt

raw_content: Two children used one seat belt while being transported for an outing.


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

raw_content: Medication logs reviewed did not include the reason medication was prescribed.

Correction Narrative: An email was received from the operation's administrator, Clifford Jackson, that included a corrective action plan indicating all the current youth med logs have been updated to include the reason for the medication prescribed. A copy of one of the med logs was also included in the email for verification.


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

raw_content: During the inspection; medication was observed accessible to the children in care and child in care pick up a pill off the floor.


raw_content: During the inspection; a post discussion was not completed after restraint conducted  on a child in care.

Standard Number / Description: 748.2851(b) - EBI Follow-Up-Caregivers involved in EBI must conduct a post discussion with child

Correction Narrative: A phone call was conducted with the operation's owner, Donyel Jack. Ms. Jack stated the operation corrected the incident report to include the post discussion with the youth and a copy will be emailed for verification.


facility_name: New Beginnings Children's Home at Canaan Land Ranch, Inc

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

raw_content: A caregiver did not adhere to the planned interventions outlined in a child's service plan when managing the child's behavior. Instead, the caregiver exhibited trigger behaviors for the child.

Correction Narrative: Spoke with staff about service plans, stated that they have monthly meetings where they go over the child's plan to ensure it is being followed.


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

raw_content: Through video evidence and interviews, it was confirmed a caregiver yelled at a child in care.  Additionally, there were other children in the room who were subjected to the yelling incident.

Correction Narrative: During a walkthrough I spoke with staff. Staff discussed their training for discipline and states his last training was in December. Staff stated they have staff meetings once a month to go over service plans and child updates. Shift communication sheet was reviewed.


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

raw_content: A child in care did not a maintenance dental care appointment on record.

Category: Child Care


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

raw_content: 2 out of 2 service plans that were reviewed had different sections left blank to include indication of history of behaviors, therapist impressions, needs and strenghts sections and other supervisions to be addressed.

Correction Narrative:
A corrective action plan was provided on 8/21/24 via email.  The Service plan was corrected and information was added regarding needs of the child.

9/5/24 Director reported they will make sure to double check and verify each other's work when completing service plans and will ensure adding information about child's needs.


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

raw_content: During this investigation it was observed that 3 out of 3 personnel files reviewed were missing current CPR cards.

Correction Narrative:
A corrective action plan was provided via email on 8/21/24 reporting the trainings would be completed by 8/24/24 and 8/26/24.

9/5/24 certificates for employees were provided during unannounced follow up inspection with current date.


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

raw_content: 1 of 2 admission assessment were missing the name and date of birth of the child.

Correction Narrative:
An email with a corrective action was sent out by Director on 8/21/24.
The corresponding Admission assessment was corrected and the missing name and DOB were added. A copy of the corrected document was provided via email.
9/5/24 Director reported they will make sure to review and double check each other's work to avoid this from happening again.


summary: 748.931(b)(2) - Annual Training- Administrators, PLSP's, treatment directors and case managers who do not hold a prof. license must have 1 hour normalcy.

raw_content: During this inspection, it was observed that 3 out of 3 personnel files were missing current normalcy training.

Correction Narrative:
A corrective action plan was provided via email on 8/21/24 reporting the trainings would be completed by 8/24/24 and 8/26/24.

9/5/24 certificates for corresponding employees were provided with current date during unannounced follow up visit.


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

raw_content: During the walkthrough of the operation, the cottage housing children in care did not have a complete first aid kit available to use in the event of an emergency.

Correction Narrative: Administrator Tammy Ibach provided photographs of the completed First Aid Kits that will be kept on the cottages and administration building. Program director Ms. Rodriguez also reported moving forward with the staff will be ensuring to utilize the first aid kits in an emergency basis. First Aid Kits will be evaluated per the standard to ensure supplies are maintained at all times.


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

raw_content: Two of two service plans and two of two serious incident reports included incomplete, inaccurate, or unclear documentation.

Correction Narrative: The operation provided the following action plan on April 25, 2024: NBCH Administration will review submitted documents (incident reports) to ensure the documents are current, true, accurate, and complete. We will ensure that all updates or additional information will be added in a timely manner.


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

raw_content: As of 07-18-2023 the data for restraints between April to June 2023 has not yet been reported to Licensing.

Correction Narrative: The operation submitted a compliance response indicating they updated the calendar they use to remind them of the reporting due date to reflect it's due on the 15th.


summary: 748.313(3)(D) - Serious Incident -Unauthorized absence of a child document whether child returned to operation, if so how long child gone from operation

raw_content: Incident reports didn't document the time when children returned to the facility.

Correction Narrative:
09/14/2023 Operation emailed assigned Inspector an updated incident report to include a space for the child's return time, date, persons involved, and the resolution of the incident. The operation is also updating their unauthorized absence log to ensure all items needed are reflected on their form.
09/20/2023 The operation updated their unauthorized absences log and Inspector reviewed for compliance.


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

raw_content: Licensing left the standard pending at the 06-02-2023 inspection to allow the operation time to locate documentation of their most recent fire inspection. The documentation was not provided as of 06-12-2023.


summary: 748.2255(3) - Operation does not employ professional who prescribes psychotropic meds-Operation obtains signed consent from consenter acknowledging info provided

raw_content: Licensing observed the operation doesn't have signed consent for a child in care's psychotropic medication.


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

Category: Physical Site

Correction Narrative:
07-12-2023. Licensing observed the operation to be free of hornet or bees nests.

06-02-2023. Licensing observed and photographed hornets nests on the grounds.


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

raw_content: Licensing observed and photographed cracked window panes in the Hope and Valor houses.

Correction Narrative:
07-12-2023. Licensing observed the windows to be free of cracks.

06-02-2023. Licensing observed and photographed cracked windowpanes in the Hope and Valor houses.


raw_content: As of 01-17-2023 the data for restraints between October and December 2022 has not yet been reported to Licensing.

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

Correction Narrative: The operation emailed Licensing and indicated the report is completed. The assigned inspector verified the report is complete in the CLASS system.


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

raw_content:
Three children's records reviewed, the service plan review and update was not completed within the six month required timeframe. Two Initial Service Plan were created on 03/20/2020  and a Review Plan was complete on 10/13/2020.

One Initial Plan was created on 09/20/2021 and Review Plan was completed on 04/05/2022.

Correction Narrative:
 Email was received from the administrator. It indicated the following: Action Plan Steps:

We have recently added a Case Manager to our program. The Case manager will keep a calendar of due dates and complete Service Plans on time including inviting case workers and other treatment team members at least 2 weeks in advance. Document can be located in SharePoint folder.


summary: 748.1347(b) - Initial Service Plan-PLSP must sign and date the plan; If PLSP disagrees with any portion of the plan, he must document issue(s) before signing it

raw_content: Two child service plans were not dated nor signed by PLSP.

Correction Narrative:
 Email was received from administrator, the email indicated the following: Action Plan Steps:
We have recently added a Case Manager to our program. The Case manager will keep a calendar of due dates and complete Service Plans on time including inviting case workers and other treatment team members at least 2 weeks in advance.  Case Manager will also ensure all parties sign and date the Service Plans. Document can be located in a SharePoint folder.


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:
Two CPS Caseworkers were not notified about Service Plan Reviews within required timeframes of 14 days.

Service Plan meeting was on 1020/2021 and CPS Caseworkers were notified on 10/15/2021.

Correction Narrative:
Email was received from administrator on 9/12/2022. The compliance indicated the following: Action Plan Steps:
We have recently added a Case Manager to our program. The Case manager will keep a calendar of due dates and complete Service Plans on time including inviting case workers and other treatment team members at least 2 weeks in advance. Document can be located in SharePoint.


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

raw_content: During the walkthrough, medications were observed to be not locked appropriately.


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

raw_content: Children in care were outside and were not supervised when they ran away from the facility.

Correction Narrative: A email was received with compliance from the Director of New Beginnings.  On 7/5/2022, the administration, reviewed the policy. The compliance plan indicated the following: All New Beginnings staff were required to review and sign the Caregiver Policy.  Administration reviewed and discussed Standard 748.685(a)(4) with all of the staff to include a one-on-one with the two staff on duty during the run.


summary: 748.3307(b)(2) - Physical Site-Common use rooms, such as dining rooms, living rooms, laundry rooms, and gymnasiums must be lighted to avoid accidents

raw_content: One light bulb of two was missing in the common area and one light bulb of two was not working in one bedroom in the girls dorm.

Correction Narrative:
12/02/2021 Electrician came to the operation and fixed all lights, photos emailed to Inspector showing that lights were working.
11/16/2021 Unannounced inspection conducted and three lights total were out, light bulbs were changed and still were out. Administrator stated they would schedule an electrician to fix the lights.


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

raw_content: Two of four staff files reviewed did not have CPR or First Aid training certificates. One of the two staff had been hired 90 days prior to 08/10/2021.

Correction Narrative: 08/31/2021 Assigned inspector received through email from operation the two staff CPR and First Aid training certificates completed/ issued on 8/19/2021.


summary: 748.3273(3) - First Aid Kits-Each one must contain antiseptic solution or wipes

raw_content: The operation did not have antiseptic solution or wipes in both dorms. There were also no tweezers in one dorm first aid kit.

Correction Narrative: 08/20/2021 Email was sent to assigned Inspector was emailed a compliance plan stating that the antiseptic wipes and tweezers were purchased for both dorms. First aid supplies have now been put on the weekly overnight inventory sheet to prevent this from occurring again.


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: Based on evidence provided in interviews caregiver made inappropriate comments towards youth in care, showed youth in care inappropriate images, as well as had inappropriate contact with youth in care.

Correction Narrative: 06/14/2021 Email was sent to assigned Inspector stating that the staff member was terminated on 05/02/2021. A staff meeting/training was conducted on 06/07/2021 reviewing recognizing and reporting abuse and personal boundaries. operation has continued to follow up with staff members individually about boundaries and maintaining a professional relationship with the residents.


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: There were two incidents on two separate occasions of suspected abuse between two youth and both incidents were not reported to Licensing.

Correction Narrative: Assigned Inspector received the following corrective action plan from Administrator: staff were trained on recognizing sexual abuse among children on 05/07/2021 and moving forward the operation will report any contact, consensual or not, between peers to Licensing.


facility_name: St. Georgia's

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

raw_content: The following required annual trainings expired in May 2025 for an active employee: Medical Consent, Recognizing and Reporting Child Sexual Abuse, Runaway Prevention, Normalcy, Psychotropic Medication, Trauma Informed Care, and Reporting Child Abuse & Neglect.

Correction Narrative:
HR process has been updated to include staff who transition to a different
status.
 When staff status changes, it would be handled in the same robust manner as
a new hire. This will include orientation to training requirements and
expectations.
 The process now includes documentation of staff previous status, the reason
for a change in status, the operational changes that would have to occur, staff
consent to change.


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

raw_content: A youth in care AWOL from the facility on 1/26/2026 at 1:48p. Documentation shows Licensing was not contacted until 7 hours later at 8:40p.

Correction Narrative:
St. Georgia Revised Action For Serious Incidents:

 St. Georgias has updated its AWOL/unauthorized absence response protocol
to include changes to our workflow (see attached Flowchart) requiring staff to
notify expected persons and entities within 6 hours of determining that a child
13 years of age or older is absent without authorization, independent of any
law enforcement or other notifications.

 All House Supervisors have received refresher training on serious incident
reporting timelines, with specific emphasis on Rule 748.303(a)(10)(A) and the
requirement that Licensing notification is not a stand-alone obligation but
inclusive of the complete reporting process that must be checked off
concurrently with other notifications.

 A Crisis Management Team has been established with a Group Call
notification key which alerts members of the team at the time an incident
occurs. Each member of the crisis team, based on their role in the facility, will
at that time issue relevant instructions to the staff on duty. This will ensure
reporting and timelines are monitored by different members of management
while incidents are ongoing.

 Compliance has established Bi-weekly review of minor incidents and review of
all major incidents to verify that all incident reports or reportable events
including unauthorized absencesare reported to relevant authorities within
the required timeframes.


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 last documented severe weather drill was conducted 06/25/2025.

Correction Narrative: CCR observed updated severe weather drill log during 1/29/26 inspection.


raw_content: Caregivers were unaware of child's bruising to their eye.


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

raw_content: Both incident reports reviewed were missing the staff's role, and one was missing the staff's full name and role.

Correction Narrative: An email was received from the Administrator on 11/5/25. The email had a new serious incident form attached that now includes sections for staff names and roles. Staff will also be trained on documenting serious incidents.


summary: 748.319(a) - AP Within five days after you receive notification of a deficiency as described in 748.317 you must notify the parents of each child admitted.

raw_content: Operation was notified of a children's rights deficiency on 06/05/25 and notification to parent/guardian was not made on or before 06/10/25.  Notifications were sent to the parents/guardians on 06/24/25.

Correction Narrative: Operation provided a compliance plan following the citation. Operation states that notifications have been completed as of 06/24/2025. Corrective actions include quarterly trainings for all staff with access to provider portal regarding parent notification and form 7266 requirements. Weekly internal audits will be completed to ensure all requirements are completed and monthly compliance report is submitted to the Administrator or Program director. Tasks and items needing completion after a citation or validation of findings are clearly documented and standardized.


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 told a child that they "deserved it" after that child was in a physical altercation with another child.

Correction Narrative: Two children interviewed confirmed staff does not talk to them in a harsh, cruel or unnecessary, or demeaning manner.


raw_content: Based on a review of documentation, it was determined that a child's unauthorized absence was not reported Licensing within the required timeframe.

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

Correction Narrative:
07/24/2025-The operation's LCCA submitted the corrective action plan to Licensing via email indicating the operation will be reviewing serious incident reporting protocols with staff as well as retraining all supervisory staff on the reporting requirements by July 30, 2025.

The operation's LCCA indicated a tracking log will be implemented to document both parent and Licensing notifications for every AWOL event, including timestamps effective date of July 30, 2025.


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

raw_content: Based on a review of documentation, it was determined that a child's unauthorized absence was not reported to the parent within the required timeframe.


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

raw_content: Upon request from Licensing, the operation did not furnish or make the requested child record (runaway prevention safety plan) accessible for review.

Correction Narrative:
07/24/2025-The operation's LCCA submitted the corrective action plan to Licensing via email indicating the operation has reviewed documentation access procedures as well as will ensure that all requested records are immediately available for Licensing review.

The operation's LCCA indicated the operation will be transitioning to a full digital system as well as all records will be available on the operation's platform.

Additionally, the operation's LCCA reported staff will be retrained on proper file organization and access protocols by July 30, 2025.


summary: 748.463(e) - Unauthorized Absence Eval-results of each overall operation eval for unauth absences must be avb to CCR for review and reproduction upon request

raw_content: The operation did not have the evaluation of unauthorized absences available for review by Licensing.

Correction Narrative: The operation provided a compliance plan by email on 05/27/2025. Operation states that the operation will implement an overall evaluation of runaways per standard 748.453(e). Operation will review all these runaway incidents and document the review.


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

raw_content: A child in care was restrained when the situation was not an emergency.

Correction Narrative: Operation states that all staff involved in the incident were terminated. Operation has undertaken a complete staff restructuring. Increased criteria for new hires. Two staff were interviewed; interview were documented in chronology.


summary: 748.2551(c)(1) - EBI Implementation-Caregiver must minimize risk of physical discomfort, harm, or pain to the child

raw_content: It was corroborated by staff and children in care that a staff member performed an EBI by pushing children up against the wall.

Correction Narrative: Operation terminated all staff involved in the incident. Operation has undertaken a complete staff restructuring by increased criteria for new hires. Two staff were interviewed; interview were documented in chronology.


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

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


raw_content: Corroborating information from multiple sources state that a staff member and a child in care had a relationship that was too close and exceeded professional boundaries.


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

raw_content: Personnel records reviewed show Licensing Affidavit for Applicants for Employment forms not completed and or notarized.

Correction Narrative: On 05/29/2025 the operation provided a follow-up compliance plan by phone. Operation states that they have since reviewed all staff files to ensure employment affidavits are complete and updated. They have also implemented use of software to track required documents by individual staff along with due dates. Automatic alerts and reminders are generated through this case management software.


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

raw_content: A review of personnel records shows that an active employee who transports children in care does not have a state issued driver's license.

Correction Narrative: On 05/29/2025 the operation provided a follow-up compliance plan by phone. Operation states that they have since reviewed all staff files to ensure driver's licenses are valid. They have also implemented use of software to track required documents by individual staff. Automatic alerts and reminders are generated through this case management software.


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

raw_content: Drug test results are not complete. No positive or negative results are documented.

Category: Organization and Administration

Correction Narrative: On 05/29/2025 the operation provided a follow-up compliance plan by phone. Operation states that they have since reviewed all files to ensure drug test results are updated. They have also implemented use of software to track required drug tests by individual staff along with due dates. Automatic alerts and reminders are generated through this case management software.


summary: 748.2453 - Emergency Behavior Intervention-Only a qualified caregiver may administer emergency behavior intervention, except short personal restraint

raw_content: Two caregivers did not implement a restraint during an emergency situation. Children in care assisted in breaking up the fight.

Correction Narrative: On 05/29/2025 the operation provided a follow-up compliance plan by phone. Operation states that two staff involved in the incident were terminated and no longer working at the operation. EBI policies and procedures have been reviewed with remaining direct care staff.


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

raw_content: Childs signature or refusal to sign the service plan is missing.

Correction Narrative: On 05/29/2025 the operation provided a follow-up compliance plan by phone. Operation states they have implemented use of software to track required documents along with due dates. Automatic alerts and reminders are generated through this case management software.


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

raw_content: Medication was observed not in a locked container.

Correction Narrative:
Corrective Action
Assessment of Current Medication Storage Practices
-Conduct an immediate review of current medication storage methods across the facility.
-Identify all locations where medications are stored.
-Determine whether existing storage complies with the locked container requirement.

Implementation of Secure Storage Solutions
-Ensure all medications are stored in appropriate locked containers.
-Purchase lockable storage units or upgrade current storage to include locks, if necessary.
-Ensure the designated storage area for medications is separate from general storage or high-traffic areas.
-Label storage units clearly to prevent misuse or confusion.

Staff Training
-Train staff on proper medication storage and access procedures.
-Conduct mandatory training sessions emphasizing the importance of secure storage.
-Provide written guidelines outlining medication handling and storage requirements.
-Include procedures for checking locks and ensuring compliance during daily operations.

Regular Inspections and Monitoring
-Implement a schedule for routine inspections of medication storage areas by lead staff.
-Conduct weekly checks to verify all medications are stored in locked containers.
-Use a checklist to document compliance and identify any issues or staff concerns.
-Address non-compliance immediately by retraining staff or replacing faulty storage units.

Emergency Access Procedures
-Develop and communicate procedures for accessing medication in emergencies.
-Assign key staff for medication storage units.
-Maintain a log of authorized personnel with access to storage keys or combinations.
-Train staff on emergency access protocols to ensure medications can be retrieved promptly when needed.

Documentation and Record-Keeping
-Maintain accurate records of medication storage and access.
-Use a logbook to record when medications are added, accessed, refused, or removed.
-Document storage inspections and any corrective actions taken.
-Document medication destruction

Policy Update and Communication
-Update the facility's written medication storage policy to reflect regulatory requirements.
-Distribute the updated policy to all staff and review it during staff meetings.
-Post the policy in medication storage areas for easy reference.


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

raw_content: Recreational calendars provided for the past 90 days did not outline an indoor & outdoor recreational activity.

Correction Narrative:
Corrective Action
 Assessment of Current Practices
-Conduct a review of existing recreational schedules, resources, and activities.
-Evaluate whether current activities meet the developmental, physical, and emotional needs of children.
-Identify gaps in indoor/outdoor activity offerings.

Comprehensive Activity Plan
-Create a detailed schedule that includes daily indoor and outdoor activities tailored to the children's diverse needs and interests.
-Discuss with staff, caregivers, and children to gather input on desired activities and interests.
-Incorporate structured and unstructured activities, ensuring a balance of active, creative, and relaxing options.
-Plan for weather-appropriate alternatives for outdoor activities.

Staff Training
-Train staff on their roles in implementing and supervising recreational activities.
-Educate staff on the importance of encouraging recreation for child development.
-Assign specific responsibilities, such as activity leaders or coordinators.

Necessary Resources
-Ensure the availability of equipment, materials, and spaces for activities.
-Conduct an inventory of current supplies and identify needs purchase needed items
-Designate safe indoor and outdoor spaces for activities.

Implementation of Daily Activities
-Implement the new daily activity schedule.
-Post schedules in visible areas for staff and children.
-Monitor participation to ensure engagement.

Monitoring and Improvement
-Regularly monitor activity and make improvements as needed.
-Gather feedback from children and staff regarding the activities.
-Adjust the schedule based on feedback and observations.


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

raw_content: 5 out of 10 serious incident reports reviewed identified incidents as both serious and reportable but the incidents were not reported to the Texas Abuse & Neglect Hotline.

Correction Narrative:
Corrective Action
Assessment & Development
-Collect data on past incidents to understand the frequency and nature of reporting delays.
-Determine why serious incidents are not being reported promptly (e.g., lack of awareness of procedures, inadequate training, communication breakdowns, etc.).

Update Incident Reporting Procedures
-Revise policies to clearly define the steps and timelines for reporting serious incidents, including suicide attempts, to Licensing.
-Develop a flowchart or checklist that outlines the reporting process step-by-step.
-Establish a clear communication plan that ensures all staff are informed of the minimum standards and understand their roles in the reporting process.

Training
-Develop a comprehensive training program for all staff on recognizing and reporting serious incidents in a timely manner.
-Emphasize the importance of timely reporting and the specific requirements of regulation 748.303(a)(12)(A).

Monitoring & Compliance
-Establish a schedule for weekly audits of incident reports to ensure compliance with reporting timelines.
-Use a checklist to verify that all serious incidents are reported to Licensing promptly.
-Implement a system of accountability where staff members are held responsible for delays or failures in reporting.
-Provide the Texas Abuse & Neglect Hotline phone number for all relevant staff.


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

raw_content: During the walkthrough a  bag of rice and potatoes were stored in a contatiner on the floor in the pantry.


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

raw_content: During the walkthrough a dresser in one of the boys room had two missing dressers.


summary: 748.313(3)(D) - Serious Incident -Unauthorized absence of a child document whether child returned to operation, if so how long child gone from operation

raw_content: The unauthorized absence log does not indicate how long the child was gone from the operation.

Correction Narrative: St. Georgia's GRO maintains an Unauthorized Absence Annual Summary Log to document unauthorized absences of youth placed at the facility. The individual logs include documentation of the date and time that the youth were noted as being absent from and returned to the facility. The duration of the youth's absence could be derived from these data points, which were recorded at the times of each respective incident. A new line will be added to the updated Unauthorized Absence Annual Summary Log to include the amount of time for the absence from the operation and if the youth discharged from the facility without returning.


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

raw_content: A child's preliminary service plan is dated 01/02/24 and signed 02/02/24.

Correction Narrative: The administrator of the operation states that they are reminded of due dates via Extended Reach. The operation will utilize the system to get preliminary service plans completed timely.


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

raw_content: It was determined that a child in care was in a physical altercation with other children in care as well as with a staff member that resulted in the child be given a ticket by local law enforcement who responded to the incident at the operation. It was concluded that this incident was not reported to the Hotline.

Correction Narrative: The operation conducted a mandatory meeting on 4/19/2024, Administration re-educated staff on the items that must be reported to Licensing, the police and DFPS/caseworker. This information will also be posted in the staff binder for review during a serious incident.


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

raw_content: It was noted that staff indicated a child was in a Prone position for over 1 minute.


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

raw_content: One medication log reviewed was missing the signature of the staff member who administered the medication.

Correction Narrative: There was a complete reeducation training at a staff meeting on medication logs, paperwork, and administering medication for all staff on 04/05/24.


raw_content: One service plan reviewed contained inaccurate information and incomplete sections.

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

Correction Narrative: The Operation will attached emails to service plans moving forward to show that information being requested from DFPS or other agencies that is not being included in the service plan has at least been requested multiple times over a spread-out time frame.


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

raw_content: Multiple medication logs reviewed contained inaccurate dates. Multiple medication logs reviewed contained an inaccurate pill count.


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

raw_content: The operation did not have an updated Unauthorized Absence log during the inspection.

Correction Narrative: The operation has come into compliance by creating an unauthorized absence log.


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

raw_content: After reviewing the documents provided, the childs Preliminary Service Plan noted multiple pronouns when referring to the child, an SIR provided did not include the circumstances surrounding the incident, an SIR provided did not depict the resolution of the incident, an SIR provided did not record the childs date of admission and a document submitted as the suicide screening did not have the name of the document, the name of the child nor did it have a date recorded on it.

Correction Narrative: As per the Administrator, due to a transition between LCCA's, the pronouns for the resident were changed due to an oversight. A tab has added to include pronouns in their system to avoid any confusion. The operation's plan to address this is to ensure that residents identify their pronouns during the Admissions Assessment. The pronoun provided will be used on all assessments moving forward. An Admission Assessment was also provided with the added slot for pronouns. An additional Admissions Assessment was also provided to reflect a more detailed sample addressing the treatment services a child's will be provided while in the care of the operation. Any and all documents will be detailed enough to provide the required information and will be reviewed and approved by the Administrator to ensure compliance.