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

raw_content: During forensic interview, victim child alleged to have been chock by the aggressors during while sexually been assaulted. Victin child stated alleged to not been able to breath while being chocked.

Correction Narrative: The operation provided a written correction. In its correction, the operation stated that staff participated in a training on 1-25-24 which covers the area of supervision. Follow up by inspection was completed on 4-10-24. Copy of sign in sheet for SIR training conducted on 2-9-24 was provided to me and photo taken.


state: TX

facility_name: Unity Children's Home - Girls

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

raw_content: Victim Child alleged that staff were aware of the incident where residents had nonconsensual sex inside the facility and did not report it., did not take her to the hospital and did not notify law enforcement.

Category: Individual Standards Evaluated

Standard Risk Level: Medium High

Corrected at Inspection: No

Correction Narrative: The operation provided a written correction via email. In its correction, the operation stated that Unity staff participated in a training covering reporting SIR timely on 2-9-24. Follow up by inspection was completed on 4-10-24 at the facility. Copy of the SIR training sign in sheet with training date 2-9-24 was provided to me and copy taken.


summary: 748.303(e)(2)(A) - Serious Incident-Report to Licensing no later than 24 hours after disaster or emergency that requires an operation to close

raw_content: Resident in care was taken to dental office for dental repair and not reported within the required time frame.

Standard Risk Level: Medium

Correction Narrative: Unity Children's Home understands the above standard rule regarding reporting and documenting serious incidents within 24 hours of the occurrence. Administrative staff, supervisors and direct care staff met on 1/25/2024 to discuss the protocol regarding reporting serious incidents and other occurrences.  In addition, the policy regarding documenting, and communicating these occurrences were reviewed. Staff were given a refresher on the information that is and is not reportable but may still require documentation. Serious Incidents are shared and reviewed by assigned staff on each shift with the administrative staff. This sharing and communicating of information will allow for assurance that no incidents are being missed that warrants reporting. A follow up training of serious incidents and reporting is scheduled for 2/9/2024.


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

raw_content: Serious incident reports received are missing pertinent information.


summary: 748.3353(b)(2) - Video cameras only used to supervise children when specific criteria met. Document justification in child's service plan & ensure alternative privacy

raw_content: Records reviewed on all six residents. There was not an individualized statement within each child's service plan indicating the need of a camera within the bedrooms.

Standard Risk Level: Medium Low

Correction Narrative: The administrator stated that the operation understands the importance of adhering to minimum standards of the State regarding the use of video camera for supervising children. The administrator stated that children service plan moving forward shall clearly state the justification for camera use in the bedrooms. follow up by inspection was completed during HM inspection at the facility.


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

raw_content: It was found that a child was not provided a prescribed pre diabetic medication for a month due to the medication not being delivered.

Correction Narrative: Written correction was sent via email. In the correction, the operation stated that it understands the importance of ensuring medications are delivered or picked up in time to avoid missed dosages. The agency protocol for receiving and delivery of medications has been reviewed in a meeting conducted on 12/21/2023 with required staff. The agency assigned staff will complete an overview of medications prescribed by physicians and psychiatrists for the assigned children at each medication consultation. The medication logs will be reviewed to ensure the medication, dosage, time, and RX follow the medication prescription. Follow up by inspection will be conducted due to the standard being Medium-High weighted. Follow up by inspection was also conducted.


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

raw_content: It was determined a staff member has fallen asleep while being responsible for children in care with significant high risk behaviors.

Standard Risk Level: High

Correction Narrative:
The operation sent its written correction via email. In its correction, it stated that Unity Children's Home understands the requirements for newly hired and tenured employees to understand and be trained in maltreatment of children. It is with hope that an understanding of the symptoms and risk factors for children surrounding this trauma is understood and complied with by everyone. Unity Children's Home has a zero policy regarding any employee violating children's rights. Staff are made aware that minimum standard violations can result in dismissal from the agency.  Employees are scheduled to revisit the policy regarding Children's Rights to be free of abuse, neglect, and exploitation on 1/25/2024.

2 staff were interviewed during an inspection, and they confirmed that they participated in the refresher training dealing on policy, children's right and supervision on 1-25-24 at the facility. Copy of the training sign in sheet was viewed. 2 children were interviewed, and they stated that staff members are always supervising them at the 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: It was determined that a staff member neglected to appropriately supervise children with high-risk behaviors.

Correction Narrative:
The operation sent its written correction via email. In its responds, it stated that all staff have been trained in supervision to help create a more caring and supportive environment. However, additional training is scheduled for 1/25/2024, to ensure all staff are aware of the supervision policy and to reiterate the imperative need to continuously provide direct supervision.  Impromptu checks into the facility will continue to be provided so that communication, problem solving, and increased teamwork remain effective.

2 staff were interviewed during an inspection and they both confirmed that they participated in a supervision refresher training at the operation. Administrator also confirmed that the supervision training took place on 1-25-24. Copy of the staff sign in sheet for the training was viewed.


summary: 748.2001(a) - Administration of Medication-Must obtain a general written consent to administer routine, preventive, & emergency medications

raw_content: During the course of the investigation, it was determined that consent was not obtained for medication.

Correction Narrative: Unity Children's Home understands the above standard rule regarding obtaining written consent for administering routine, preventive, and emergency medications. Unity follows strict medication guidelines to ensure the agency remains in compliance with minimum standard rules. The agency will continue to ensure that medications have general written consents.


summary: 748.535(3)(F) - Child-care administrator responsibilities-Ensuring that operation complies with applicable rules of chapter 748 and other applicable rules and laws.

raw_content: The administrator was made aware of a child in care not receiving a prescribed medication but the child in care was still not receiving the medication two weeks after meeting.

Correction Narrative: The Administrator understands the responsibilities and applicable rules of Chapter 748. To ensure compliance the Administrator will complete weekly facility checks, document any rules violations, consistently apply policies and procedures, meet with treatment team members bi-monthly, and invest in training. Compliance rules affect everyone so setting an example and making sure everyone is accountable will instill a positive culture of compliance, avoiding issues from inconsistency.


raw_content: One medication, prescribed by a healthcare professional, was not administered to the child in care.

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

Correction Narrative: Unity Children's Home staff members receive ongoing training and information through continuing education and in-service training. Some information included in the training includes: The purpose of the medication, benefits and risks associated with medication use, contraindications. Side effects, missed doses, potential implications of diet and exercise when using medications, and the importance of taking medications as prescribed, including, when applicable, the identification of potential obstacles to adherence. All staff were required to complete Medication Training by February 20, 2024, to ensure that they received education to develop effective consistent medication reconciliation and the important role they play in the process. Training will be required every 6 months to ensure that this process eliminates unnecessary redundancies in this standard area. In addition, pharmacy changes occurred, and the health care provider process was revisited to identify the policy and procedures after an appointment.


summary: 748.1437(5) - Discharge/Transfer Documentation-Must include list of medications child is taking, dosage, frequency, and reason prescribed

raw_content: One prescribed medication was not included in the child in care's discharge paperwork.

Correction Narrative: Unity Children's Home understands the importance of including prescribed medication in the child in care's discharge paperwork. Staff designated have been re-trained regarding the policy of medication administration and the documentation of accurate records. Training on this refresher medication policy was completed on 1/22/2024. The implementation of this process ensures that roles are clearly defined and responsibilities for medication administration and documentation reconciliation.  In addition, weekly medication checks that ensure the process(medication(s) prescribed, discontinued, refilled) meets all pertinent regulatory requirements are assigned which helps strengthen the importance of this process.


summary: 748.1337(b)(1)(D)(viii) - Initial Service Plan-Include instructions to caregivers about actions to take or conditions to be aware of in order to meet child's special needs

raw_content: One prescribed medication was not listed in the child in care's service plan.

Correction Narrative: Unity Children's Home required the treatment team members that include the Clinical Director and Case Managers to review the specific minimum standard noted above to ensure comprehension regarding instructions on conditions to meet special needs of children they are assigned to. The review was conducted via a meeting on 2/19/2024. Communication and documentation of this information is required with DFPS (Department of Family and Protective Services) workers. This communication should be related to services, behavior analysis, education, and medical needs at the minimum. This interchange of information will reflect in all plans to ensure the actions needed are noted to meet the clients mental and physical needs and to remain in compliance with minimum standards.


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

raw_content: Program Manager stated in her interview that she prefills the medical form 2403.

Correction Narrative: Unity Children's Home will not accept or utilize forms specifically (K905-2403) that are prefilled from DFPS regarding their clients. Each client will have an individualized form completed the day of an appointment by a Unity Home designated member of staff. This information and instructions on how to complete the required form was completed with designated staff on February 9, 2024.  This will ensure a more thorough review of the form after noted services by the medical provider have been documented.


raw_content: Multiple sources reported witnessing staff sleeping or resting their eyes while supervising children including children with high risk behaviors.

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

Correction Narrative: Unity Children's Home understands the importance of caregiver(s) to provide supervision necessary to ensure each child's safety and well-being. Training was completed for all staff regarding supervision on 2/9/2024. Training covered positioning, scanning, being alert and able to see or hear the child for immediate assistance. Staff were explained that supervision provides a supportive, and positive work environment. Unity provided an inphograpic for all staff as a visual aide to remind them of the 24-hour awake all shift policy. This will help communicate information quickly and clearly. The polices will be reviewed every 6 months with staff to reiterate continuous supervision and monitoring of youth.


raw_content: Staff was observed asleep while supervising children with high-risk behavior putting them in substantial risk of harm.

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

Correction Narrative: Unity Children's Home completed training on 2/9/2024, that retrained direct care staff and administrative staff on how imperative it is to understand the children's rights and adhere to minimum standard. Children's rights were reviewed and discussed. The Administrator and other designees will complete unannounced visits to the facility to ensure programmatic compliance and checking on children(s) safety and security. In addition, training on reporting significant occurrences was reviewed with staff. Unity has established a tracking system for reportable incidents.


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

raw_content: Upon review of the personnel  records, one of the caregiver was missing an affadavit.

Correction Narrative: A copy of the affidavit for staff was received.


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

Correction Narrative:
A caregiver pulled the hair of a child in care, grabbed the child by the neck and threatened the child.

4 children were interviewed on discipline, hair pulling, being threatened by staff, and punishhment. No children made any outcries of such. No concerns were found during the interviews.


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

Correction Narrative:
A caregiver used profane language and directed it toward a child in care when speaking to the child.

4 children were interviewed on discipline, hair pulling, being threatened by staff, and punishhment. No children made any outcries of such. No concerns were found during the interviews.


summary: 748.311(8) - Serious Incident Documentation-Includes interventions made during and after the incident, i.e. medical interventions, contacts made, other actions

raw_content: The reports are not detailed in what interventions the caregivers actually used. It is mostly stated that staff redirects the children but does not specify how. For a fight, it was stated that the residents were separated but does not specify how.


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

raw_content: One of four caregivers started in 2020 but his TB test was from 2013. It was not indicated in his employee binder that he previously worked for any other RTC/GRO/CPA.


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

raw_content: Four of four records reviewed did not contain a copy of the admission assessment, preliminary, or daily progress notes. Three of the four records did not have any updated incidents reports from 2022.

Standard Risk Level: Low


summary: 748.2151(g) - Medication record-medication records of prescription & non-prescription medication dispensed to the child must be incorporated into child's record

raw_content: Four of four records did not include their past medication records.


summary: 748.1339(a)(2) - Initial Service Plan-Team must include person designated to make decisions regarding a child's participation in childhood activities

raw_content: Four of four records reviewed did not contain a signature from the DFPS caseworker.


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: Operational employees did not notify Licensing of police responding to an incident at the operation.

Correction Narrative: An email was received from the operation's administrator which included the response to the citation issued. The response provided indicated the operation disagrees with the citation but was informed to report any time law enforcement responds to the operation to be on the safe side. The response indicated the operation will maintain compliance regarding this in the future.


raw_content: The Administrator failed to mention the injury sustained by a resident (a brace on her right wrist for 7 days), as a result of a physical altercation, when she made a report to the Abuse and Neglect hotline.

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

Correction Narrative: Unity Children's Home understands and cooperates with reporting incidents according to minimum standards. In review of the above deficiency, it was determined that the incident was reported to the hotline in advance of the youth returning from the Emergency visit. Administrators have now been informed to make Licensing aware of any event where additional pertinent information is received after statewide intake has been notified in all reportable cases and within 24 hours of obtaining additional information regarding the occurrences. In the noted investigation records reviewed clearly indicate the times of the notifications, so at the onset report the LCCA did in fact make true and reportable facts to the statewide hotline.


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

raw_content: The operation did not make a prudent judgement when placing camera in to bedrooms without prior approval from treatment team.

Correction Narrative: During the follow-up, the operation confirmed that letters will be sent to the caregivers for their approval of the cameras being in the children room.  Cameras will not be live until letters are approved.


summary: 748.3353(b)(2) - Video cameras only used to supervise children when specific criteria met. Document justification in child's service plan & ensure alternative privacy

raw_content: The operation placed video cameras in the bedrooms and therapy room without prior approval from each girls treatment team per minimum standards.

Correction Narrative: The video camera is no longer visible in the therapy room but is visible in the children's bedroom.  Cameras will need to be removed from the bedrooms immediately.


summary: 748.1101(b)(3)(E) - Children's rights-privacy to send/receive unopened mail,have phone conversations,keep journal,have visitors unless the child's best interest

raw_content:
The purpose of this rule is to ensure the privacy of the child while in therapy.  During the inspection, a camera was observed in the therapy room and requested to be remove prior to leaving the operation.

The operation did remove the camera in the therapy treatment room prior to licensing leaving the inspection.


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: A child's file was reviewed; there was no unauthorized debriefing documentation. The administrative staff were unable to produce to requested documentation prior to the conclusion of the inspection.

Correction Narrative: The operation made the necessary changes to the unauthorized absence form. The treatment team will ensure this form is being completed if a child leaves the operation and comes back.


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

raw_content: The unauthorized absence log was observed missing the required information. The log was also observed with untrue/inaccurate information documented.

Correction Narrative: The operation has made the necessary changes to the unauthorized absence form. A copy of this form was provided to review.


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

raw_content: Investigation interviews indicate care givers became aware on 09-18-2022 of allegations of a care giver being sexually in appropriate in the presence of children in care and there was a miscommunication among the care givers resulting in this care giver being able to return to work with no restrictions or precautions in place until 09-19-2022 when an additional similar allegation prompted the operation to implement a plan.


summary: 748.1101(b)(7) - Child's rights-Make complaints/calls/reports w/o interference,coercion,punishment,retaliation,threats.Right to make them anonymously

raw_content: According to the operation, a child in care was asked to write a statement regarding a report made by the child in an effort to not put anyone in any type of litigation.

Correction Narrative: When interviewing 3 girl it was apparent that they are not being coerced from informing third parties about incidents at their placement.


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

raw_content: Upon inspection of facility the evacuation plan was not posted in any of the units or around the facility (CI)

Corrected at Inspection: Yes


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

raw_content: During inspection it was noticed that medication for a child in care was not logged correctly. There were two medication logs for one medication, stating there were 3 pills left on one log and 28 on another log. The pill card or script card had 1 pill. (CI)

Category: Medication


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

raw_content: During the walk through of the facility it was noticed that doors were broken, graffiti was on the unit walls/ doors, and walls were not in good repair


summary: 748.3441(m) - Food Preparation-Food must be thawed in the refrigerator, in cold water in a leak-proof bag, or in the microwave

raw_content: During walkthrough of kitchen, it was noticed that meat in the refrigerator was not properly thawed. Food was seen opened and bleeding on a sliver pan in the refrigerator. Photo was taken. (CI)


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

raw_content: 1 out of 4 files reviewed does not have a signature of the treatment director


summary: 748.3369(e) - Bedding-Bunk bed must have attached bedrails; bedrails & the mattress supports must not be an entrapment hazard

raw_content: During the walk through of the facility it was noticed that two bunkbeds did not have a bedrail on the top bunk


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

raw_content: During the walk through it was observed that 5 beds were missing cover protectors in the girls unit.


raw_content: It was observed during the inspection that raw frozen chicken legs were being thawed in the sink. The staff moved the chincken legs from the sink in to the refrigerator.

Standard Number / Description: 748.3441(m) - Food Preparation-Food must be thawed in the refrigerator, in cold water in a leak-proof bag, or in the microwave

Category: Physical Site


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

raw_content: 6 of 6 children interviewed stated staff use profanity towards them and around them including slip ups.


summary: 748.2301(b)(2) - Disciplinary Measures-must not be physically or emotionally damaging to the child

raw_content: Four out of six clients stated that staff have made inappropriate comments towards children about their sexual identity. Three out of Six staff denied making inappropriate comments towards children about their sexual identity. Three out of six staff agreed calling children by their government would prevent any confusion and would not accommodate a child who wanted to be called a derogatory word as their name.

Correction Narrative: I received an email from Ms. Harriet Callion stating "Iam informing that I have submitted for an Administrative Review for the above Investigation #.  I have attached the Letter that correlates with my Administrative Review Request." This will be readdressed after the administrative reviewed.  During inspection 3841259 I interviewed child at the operation referring to the follow up and a separate investigation. During the interview of 3 children there was no concerns noted as to inappropriate comments made by staff.


facility_name: Hidden Cove Residential Treatment Center

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

raw_content: Both child files reviewed did not have the reason for the medication documented on the medication log.

Correction Narrative: An email was received from the administrator detailing the steps taken by the operation to comply. The agency has reviewed all current medication logs and corrected any forms that required a reason to be listed. The past medication logs are being updated with an addendum to document the reason. The administrator has reviewed how to fill out the medication log with all staff members as well as posted the requirements in the medication room.


facility_name: 2nd Chance Treatment Center

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

raw_content: Expired food items was observed in refridgeratror in dinning room.


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

raw_content: The unauthorized absence of a 15-year-old child in care was not reported to licensing timely.

Correction Narrative: An email was received from the administrator Mr. Taylor. has instructed all staff to follow the minimum standards regarding youth being away from the facility without permission and their whereabouts are unknown. Each staff was retrained, and the signature page can be found in the document library.


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: A child in care signature was not seen on his rights form.

Category: Children's Rights

Correction Narrative: I, RCCR Tommie Moore receive an email from the case manager showing the child rights sign form. The sign form can be found in the document library.


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

raw_content: Two holes were seen on the  door in Room 1.  There was one hole seen in the hallway between bedrooms 1 and 2. There was one hole seen in room 2 on the bathroom door.

Correction Narrative: Repairs were made to the door in Room 1. Repairs were made to the hole seen in the hallway. Repairs were made to the bathroom door in room 2.


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

raw_content: The operation did not complete an annual unauthorized absence log when a youth ran at least twice from the operation.

Correction Narrative:
An email was received from case manager Amy Brackley.
Effective immediately, 2nd chance has instructed all staff to follow the minimum standards regarding youth being away from the facility without permission and their whereabouts are unknown. An unauthorized absence protocol (to include documentation of the incident, notification of law enforcement and hotline, as well as contact with the administrative team), will be implemented and followed to assure either the safe return and or appropriate tracking/ communication among agencies is followed.
The documentation can be found in the document library.


summary: 748.3303(a)(2) - Physical Site- Buildings must be clean and in good repair.

raw_content: During inspection, one of the walls in the bedroom had a huge hole in it.

Correction Narrative: A picture was taken of the hole in room 2 being repaired.


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

raw_content: The operation has not had a fire inspection conducted at this time.


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

raw_content: During the inspection 2 bathroom sink cabinets in room 1 were removed. 2 holes were seen in bathroom door. One ceiling fan was not attaced to thee ceiling wall.

Correction Narrative: During the follow-up inspection pictures were taken in the first bedroom of ceiling fan being connected to the ceilings. The holes in the bathroom were repair and the bathroom sink cabinets were covered.


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

raw_content: The allegation is related to DFPS abuse/neglect investigation. During the course of the investigation, it was determined that a staff member left the hallway for 30 minutes.  In reviewing each child's service plan bed/room checks is occur every 15 minutes.

Correction Narrative: The administrator stated a training was conducted with all employees on 2/11/2024 and 3/4/2024 thru 3/5/2024. The training consisted of a review of 2nd Chance policy and procedure (scheduling, supervision, transportation, intake process). The documents can be found in the document library


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

raw_content: A staff member failed to supervise the children in care due to staff member going to sleep during his shift which allowed children to engage in inappropriate behavior.

Correction Narrative: Effective immediately, 2nd chance has instructed all staff to follow the overnight supervision policy of positioning staff outside of the residents room with the door open until residents fall asleep. Overnight staff will conduct room checks and document room checks every 15 minutes to assure residents remain asleep and are safe. Any disturbances (restroom visits, water request, anxieties, etc.) will be documented and addressed accordingly.  Training was conducted with staff on 2/11/2024, March 4th and 5th, 2024. The documents can be found in document library.


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

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

Correction Narrative: All residents are made aware of their rights upon admission to 2nd chance and each resident has an opportunity to review, sign, and receive a copy of their rights. Additionally, 2nd chance has an open-door policy, that is explained to all residents, that they can express their safety concerns to any staff member, in a confidential format and those concerns will be addressed; including but not limited to room reassignments, one-to-one supervision, heightened supervision during outings, house meetings to address concerns, therapy, contact with case manager/ CASA. Etc. The room check sheets can be found in the document library.


summary: 748.463(a) - Unauthorized Absence EvaluationMust conduct an eval every 6 mths for unauthorized absences that have occurred during that time period

raw_content: Operation did not conducted an overall evaluation for unauthorized absences biannually as required.

Correction Narrative: Operation provided a 6-month evaluation for unauthorized absence for Jan-June 2023.


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

raw_content: One fan at the operation is supended from exposed wiring.

Correction Narrative: A picture was taken of a new fan in the staff office.


summary: 748.457(a) - Unauthorized AbsenceTriggered Review of childs unauth absences must occur ASAP, but no later than 30 days after third absence within 60-days

raw_content: A trigged review of unauthorized absences was not conducted within 30 days of a child in care's third unauthorized absence.

Correction Narrative: An email was sent from the case manager on 11-2-2023 showing that a trigger review was conducted within 30 days.


raw_content: A child in care, who was identified as in "active substance use" was released to school, where the child then absconded.

Correction Narrative: 2nd Chance will continue to provide training to staff in order to achieve and display appropriate supervision while residents are under the facility's care.  All RTC staff will become knowledgeable with appropriate supervision based off the youth's history and current behaviors placed at the facility.  These trainings will be conducted pre-service employment, bi-annually, annually, and/or as needed.  The training information will be conducted and provided by RTC Administrator, RTC Treatment Director, LPC, and/or Case Manager as well through the DFPS portal, and approved vendors ( CPR/1st Aid/AED and PAPH/EBI)   These trainings will include but not limited to DFPS Runaway Prevention, Cultural Competency, Normalcy, Trauma Informed Care, Human Trafficking, Abuse and Neglect, Sexual Abuse-information from Attachment A (if deemed necessary), and brief overview of the youth's historical and/or current behaviors.  2nd Chance will maintain the confidentiality and HIPPA regulations for all residents and work closely with our partners to protect the physical, mental, and emotional wellbeing of residents entrusted to our care.


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

raw_content: Children in care who, after multiple absences from the facility, presented with concerning weight loss and signs of illicit drug use were not offered medical evaluations upon return.

Correction Narrative: When the youth return back to the facility from a runaway event, the RTC staff will perform an overall visual health examination to determine if immediate medical attention is needed.  If deemed necessary, staff will contact the RTC Director, RTC Administrator, LPC, and/or Case Manager to follow the next procedures.  If it is determined that immediately emergency medical attention is not needed, then non-medical trauma will be noted, and the youth will be scheduled at the next available appointment with their medical provider to ensure the youth's medical needs are being met.


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

raw_content: Children in care brought marijuana into the facility and used it in the bathroom on multiple occasions.

Correction Narrative:
Effective immediately, 2nd Chance will continue to maintain client and care giver ratio on each shift to not only ensure adequate supervision, but to also assure resident safety.
 Staff will orient new residents and current residents placed in the facility to ensure the youth is knowledgeable and understands the rules on appropriate bodily searches and room searches.  These searches will be conducted to reduce the potential for contraband being brought into the facility as well as being thorough, but non-intrusive, search of each individual and their possessions.  These searches will occur when they arrive back to facility from any outdoor event such school, community events, family visitation, random room checks, etc.  The youth's searches will include the individual emptying of their pockets, taking off their shoes, backpacks, their belongings, and lifting up and/or shaking their pant legs. The searches will not only be conducted when the youth return home but also completed of their room if there is reason to believe/suspension of possible drug usage or if it is possible that the youth may have contraband in their possession.
Each time, a youth is search even if they refuse the search, the incident will be documented in the Personal and Room Search log which will include the date and time of search, a list of any unacceptable items were found throughout the search, and staff's signature who(m) conducted the search.  If any unacceptable items were discovered, the items will be confiscated, storage in a lock location, and the youth's treatment team will be notified. The RTC team will await the treatment's team directives on how to move forward with the contraband.


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

raw_content: A child in care, had not received a psychological evaluation or a DSM diagnosis when admitted into the Treatment Center.


summary: 748.459(a) - Unauthorized Absence-Triggered review of childs unauthorized absences must include, child, designated staff, and childs case manager

raw_content: Child was not present during their trigger review.


summary: 748.453(a)(6) - Unauthorized AbsenceAnnual summary log must include if LE was contacted, include name of LE agency & number of police report, if applicable

raw_content: There is no documentation of the law enforcement agency name contacted or report number in the annual summary log.


raw_content: Children were able to run away on multiple occasions due to caregivers no providing adequate supervision.


summary: 748.393(b)(2) - Active child record-Includes known allergies and chronic conditions or "no known allergies" on exterior of record or in a clearly visible location

raw_content: 4 out of 5 kid file did not have their allergies listed.

Category: Reports and Record Keeping


summary: 748.930(b)(1)(A) - Annual Training-Caregivers in operations other than cottage homes must have 4 hrs of EBI every 6 months.

raw_content: 6/6 staff files did not have any their annual EBI Training.

Category: Training and Professional Development

Correction Narrative: 6/6 staff files did  have any their annual EBI Training. The EBI traiining was conducted on 9-17-2023.


raw_content: In room one there was a hole in the wall.

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

Correction Narrative: A picture was taken of the hole in room 1 being repair.


summary: 748.3395(a) - Hand-washing-Hand-washing sinks must be maintained in good repair and kept clean

raw_content: A hand-washing sink was seen in bathroom  one clog.

Correction Narrative: A video was taken of the sink in bathroom one. The video shows that the sink is not clog at this time.


summary: 748.1217(b)(8) - Admission Assessment-At admission, must include child's current educational level & any school problems

raw_content: The child's grade level is not documented on the admissions assessment.

Correction Narrative: I received a copy of the admissions assessment from the caseworker showing that the child grade level was updated on the admissions assessment. The grade level is in section 2 on pages four and six under the educational section. The admissions assessment can be found in share drive.


summary: 748.1217(b)(1) - Admission Assessment-At admission, must include child's legal status

raw_content: The admissions assessment did not clearly state the child's current legal status.

Correction Narrative: I, received a copy of the admission assessment from the caseworker showing were the child current legal status was added. The admission assessment can be found in the external file.


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

raw_content: Two of Two child files reviewed did not contain a response for the child regarding EBI techniques.

Correction Narrative: I received an email from the caseworker. The caseworker sent over child's file in regards to EBI techniques. One child refuse and the signature can be seen on the EBI form. The other child signed and dated the EBI form stating that the techniques were discuss with him. The forms can be found in share drive.


raw_content: A child in care was admitted to a RTC but does not qualify for treatment services per the admissions assessment and the service plan.

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

Correction Narrative: I received an email from the caseworker showing how the child in care qualifies for treatment services, the child admission assessments and service plan was updated to meet the requirement. The admission assessment and service plan can be found in shared drive.


facility_name: Tree of Life RTC

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

raw_content: The operation failed to employ a full-time administrator for the operation at the expiration of the 60 days given to them in technical assistance issued by assessment on 11-17-25

Correction Narrative:
The operation sent its written correction via email. In its correction, the operation stated that Tree of Life RTC will:

Notify DFPS within 24 hours of any future administrator separation and ensure a new administrator is hired timely.

Maintain documentation of interim administrative assignments.


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

raw_content: During the review of one staff file, multiple dates of hire was observed. The date of hire for the staff in staff list is different from the date of hire on the staff file binder cover.

Correction Narrative:
The operation has implemented a quarterly staff file audit checklist to ensure all personnel records remain current, true, accurate, and complete.

Only designated administrative staff are authorized to update personnel records.

Any updates to employee information must now be completed simultaneously across all record systems.


summary: 748.363(14) - Personnel records - Include any documentation of the person's performance with the operation.

raw_content: During the review of one staff file, no document was observed regarding the staff performance.

Correction Narrative:
All completed evaluations will be immediately filed in the staff personnel record.

Administrative leadership will verify completion of annual evaluation during quarterly personnel audits.


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

raw_content: A serious incident report was missing the operations physical address, telephone number and the child's gender.

Correction Narrative: The operation sent its written correction via email. In its correction, the operation stated that it is the operations utmost responsibility to ensure that the operation remains fully compliant with regulations. The operation will continue to ensure that all paperwork ate tailored to meet or exceed the required minimum standard requirements.


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: A review of the EBI quarterly data indicates the information has not been submitted for the first quarter.

Correction Narrative: An email received from the administrator on 05/13/25 identified the following plan of correction: The operation plans set timers to submit quarterly EBI reports. Recurring reminders through calendar alerts for the 15th of the last month of each quarter with the label prepare and submit EBI quarterly report. In addition, weekly/monthly check-ins with the program manager or email summary will be conducted where the program manager informs the administrator of the data entry to show timely documentation.


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: The employee file reviewed at inspection CPR/First Aid certification was expired.

Correction Narrative:
A copy of the completed training certificate dated 04/30/25 for the staff was received from the administrator by email on 05/19/25.
During an inspection completed on 05/12/25, the administrator identified the staff had received CPR/First Aid training.
The updated plan of correction was received by email on 05/13/25 from the administrator with the following: It is the responsibility of the program manager to work with the administrator to make sure that all upcoming CPR/First Aid, EBI/CPI and other certifications are renewed before their expiration date. All staff will be notified within 10 days of training certificate expiration. Until an employee's expired certification can be renewed the administrator will require that a second person with current certifications be on duty with said employee. To get the staff member re-certified ASAP, the PM or Admin will contact the training contractor immediately to see when the next availability is to schedule re-certification training. To make sure that no certifications expire in the future, TOL RTC will use HM tasks 7 and 5 to audit and track training/documents in the staff file.


raw_content: A review of records revealed that a child's service plan was incomplete and unsigned by the administrator.

Correction Narrative: A plan of correction was received on 05/05/25 by email from the administrator identified that once a service plan has been proofread by the administrator and approved, it is then printed. The administrator will ensure that his or her signature is next on the plan after review with the child and before sending it to the child's caseworker.


summary: 748.861(b) - Pre-Service Training-If facility provides certain amount of tx svcs, caregiver must have 40 hours experience in operation that provides same tx svcs

raw_content: A caregiver employed by the operation did not have previous treatment services childcare experience, the personnel record did not show 40 hours of documented observation, prior to being on shift as a sole caregiver and the caregiver was not exempt from the observation.

Correction Narrative:
On 05/19/25, phone contact with the administrator and follow up email identified the following plan of correction: Moving forward new staff that have no previous childcare services must be supervised by another caregiver who has already satisfied the 40-hour experience requirement, and supervised child-care experience must be documented in the appropriate personnel record.
A plan of compliance received on 05/13/25, after being returned for corrections from the administrator by email identified the employee had received the required 40 hours of training but the documentation was not structured to show the employee had worked under the supervision of administration and senior staff.
A plan of correction was received on 05/05/25 by email from the administrator but returned for corrections on 05/07/25.


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

raw_content: Reference checks were not completed for the personnel file that was reviewed.

Correction Narrative:
On 05/13/25, an email with the updated plan of correction was received from the administrator with the following information: Reference checks are made by the Program Manager and/or the administrator. The plan states that reference checks will be completed 72 hours after the employee accepts and sign their offer letter. Prior to the offer letter, the operation will have the prospective employee's completed applicant interview, passed the background check, fingerprinting, provide required documents, etc. Reference checks are completed either by phone call or email. All new employees will have their employee file audited within 7 days of their first employment by the administrator. TOL will use a personnel audit file fore or the quarterly personnel file audit tracker to ensure personnel files are complete. Quarterly audits will be performed to ensure compliance.
A plan of correction was received on 05/05/25 by email from the administrator but returned for corrections on 05/07/25.


raw_content: A record review of a child's admission assessment contained information regarding another resident.

Correction Narrative: Administrator sent the plan of correction via email on 04/16/25 with an attached process plan update for the admission assessment identifying the case manager would submit the completed assessment to the LCCA to review for completeness, accuracy, and required signatures. Administrator sent an amended resident admission assessment for the child reviewed.


Standard Number / Description: 748.861(b) - Pre-Service Training-If facility provides certain amount of tx svcs, caregiver must have 40 hours experience in operation that provides same tx svcs

Deficiency Narrative: A caregiver employed by the operation did not have previous treatment services childcare experience, the personnel record did not show 40 hours of documented observation, prior to being on shift as a sole caregiver and the caregiver was not exempt from the observation.

Correction Narrative:
A second email received from the administrator on 04/23/25 identified additions made to the original forms supplied to include differentiation between job shadowing and pre-service training, dates completed, signature of senior staff, and indicate the staff member that is new to childcare must be supervised at all times by another caregiver who has already satisfied the 40 hour experience requirement, and the supervised child-care experience must be documented in the personnel record. The 40-hour preservice log for new employee was also amended in the wording to identify shadowing senior staff to encompass the appropriate number of hours and evaluation.
A plan of correction sent by email on 04/16/25 by the administrator identified an update to the 40-hour pre-service log for new employee form to indicate that each staff would participate in a two-week long, 4 hours per day orientation and introduction that included a new employee observation/shadowing by senior staff.


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

raw_content: During a walkthrough inspection of the operation, milk, hot dog and hamburger buns, wheat bread, and tortillas were found past the sell or use by date. The operation disposed of the expired items while inspector was present.


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

raw_content: During a follow-up walk through conducted at the operation, the sink in the bathroom remains leaking and the blind in the second bathroom downstairs is still broken.

Correction Narrative: During a walkthrough of the of the operation, the sink was no longer leaking, and broken blinds had been replaced in the bathroom.


summary: 748.3351(4) - Interior Space-provide bedrooms with at least one window with outside exposure to natural light

raw_content: During a walkthrough of the operation, the windows in the bedroom do not have natural light to the room as the windows are now blocked with privacy panels due to an add-on room to the house for the case manager.


summary: 745.8411(b)(2) - Responsibilities - Provides access to all areas of the operation

raw_content: During a walkthrough of the operation the door to the casemanagers office was locked and unable to be accessed.

Correction Narrative: During a walkthrough of the operation, the case manager's office was unlocked for observation.


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

raw_content: The evacuation floor plans hung in the operation do not reflect an acurate depiction of the exit route or shelter in place location.

Correction Narrative: During the follow up to the operation, inspector observed corrections made to the fire escape plan and shelter in place documents.


raw_content: During a walkthrough conducted at the operation, there was a broken electrical outlet, water leaking under a bathroom sink, exposed wiring inside a bathroom, broken window blind, screens that were torn on the porch area, broken tiles, and room transitions that pose a tripping hazard.


summary: 748.2101(7) - Medication storage & destruction-remove medication on/before the expiration date & destroy it in a way that ensures children do not have access

raw_content: During a walk-through of the operation, there was several containers of  over the counter medications that were expired.

Correction Narrative: An emailed plan of correction was received from the operations' administrator on 03/07/2025 with the following information identified: The program manager and/or the administrator will audit the over-the-counter medications weekly to make sure that all expired medications are removed from the active stock and properly exposed of.


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

raw_content: It was determined that one bedroom did not have blinds on the window,

Correction Narrative: The agency has a work order for this to be fixed by a maintenance person that comes to the home every week.


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

raw_content: It was determined that the operation did not report three different incidents with a particular child.

Correction Narrative: The agency implemented a safety plan where they will search the child to ensure nothing of hazard is brought into the home.


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

raw_content:
A staff member did not follow the operations policy to check for a body part to
ensure the child's presence in the facility

Correction Narrative: An email with attached documents was received on 12/04/2024 from Tree of Life LCCA. The attached documentation identified plan of correction regarding 748.126(b) included that on October 17, 2024 an update was made to the operation's "24-Hour Awake Supervision Policy". The phrase, "Also, for any child on Heightened Supervision Staff will check for a visible body part and notate it on the supervision log." According to the document the victim child's "Heightened Supervision" log was also updated on October 14, after the AWOL and it stated during "bedtime hours" what body part was visible during all nighttime checks. The operation plan identified, "Since OV's AWOL on October 9, 2024, TOL's staff has received two (2) trainings; "Supervision Training" on October 30, 2024, and "Negligent Supervision Training" on November 22, 2024, to continue training staff on the importance of effective supervision. The trainings are attached documents.


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

raw_content: A staff at the operation did not provide adequate overnight supervision checks which resulted in the child's subsequent AWOL, involvement in criminal activity, and injury.


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: Caregivers failed to notify licensing of a child in care of an incident involving the child sustaining an injury.

Correction Narrative: Administrator emailed the compliance plan. As a result, they will report all serious incidents will be reported to licensing.


summary: 748.303(a)(3)(B) - Serious Incident-Report to parents allegations of abuse, neglect, or exploitation of a child directly after ensuring the child's safety.

raw_content: Caregivers failed to notify the parent of a child in care of an incident involving the child sustaining an injury.

Correction Narrative: Administrator emailed the compliance plan. As a result, when a child is involved in a "serious incident", if family is involved, the caseworker and the family will be notified no later than 24 hours of the serious incident. The notification will include all pertinent parties being notified by phone and followed with an email.


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

raw_content: Operation was out of ratio as one of the children required 1 to 1 supervision at the time of the incident.

Correction Narrative: Administrator emailed the compliance plan. As a result, Tree of life will make sure that their facility is within ratio. Tree of Life will also make sure that staff is working with the child(ren) are also informed of ratio requirements to include any special supervision provisions.


raw_content: Staff failed to provide adequate supervision which caused a child in care to sustain injuries.

Correction Narrative: Administrator emailed the compliance plan. As a result, Tree of life RTC will ensure that all children placed in their care are adequately supervised at all times and especially when outside of the facility. All children will remain within visual or hearing distance of staff at all times.


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

raw_content: The service plan reviewed did not have specific level of supervision for when the child is participating in outside activities.

Correction Narrative: Administrator emailed the compliance plan. As a result, treatment plans will now always and will continue to be proofread by the administrator to ensure that they include pertinent information under the appropriate titles. Every treatment plan will be completed based on each child's specific needs. After a treatment plan is completed if a child's behaviors or needs change, the treatment plan will be modified to reflect the changes and the child's CPS caseworker will be notified.


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

raw_content: The refrigerator's thermometer was not at 40 degrees or below. There was also food in the freezer that was not properly stored but it was corrected at inspection.

Correction Narrative: The operation stated in their follow-up they purchased a new refrigerator for their operation on May 3rd, 2024.


summary: 748.4083(a) - Vehicle and maintenance-Must maintain a vehicle in a safe operating condition at all times

raw_content: The vehicle used to transport children was observed to have the check engine and tire pressure light on.

Category: Transportation

Correction Narrative: The operation sent follow-ups via e-mail stating the necessary repairs were made to the vehicle on 5/10/2024.


summary: 748.125(e)(1)(E) - You must adhere to recommendations of the MH professional and update the childs safety/service plan's if child is at high risk for suicide.

raw_content: It was determined that the operation did not follow the safety plan in place to ensure the safety of a resident with known high-risk behaviors.

Correction Narrative:
In addition to Seth's current Safety Plan he will be:

Closely monitored and/or always shadowed by the staff while awake to ensure his safety.
Seth will be allowed the privacy of changing clothes in his bedroom, and he will be allowed no more than 5 minutes.
When Seth needs to use the restroom, the door must not be locked. The door is always to be open at least 3 inches unless he is using the toilet to defecate, he will be allowed 5 minutes.
When he goes in the restroom to shower, he is allowed 10 minutes to shower and the door to the restroom must be left open at least 3 inches; staff will be right outside of the restroom monitoring his time and safety.


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

raw_content: It was determined that one bed wood panels were not secure, and a chair was observed to have broken wood pieces.

Correction Narrative:
Tree of Life RTC will inspect the furniture and bedding weekly when the facility walk-through is conducted while checking for any other issues in the facility. This is our way of ensuring that all furniture and/or equipment is up to Minimum Standards. **Physical follow-up will be conducted at the next POA inspection.
Please note that at Tree of Life RTC, we take pride in being compliant with Minimum Standards, the services we provide to the children we serve, and in caring for the staff that help us continue to be successful. We also appreciate the critiques and continued feedback that we receive from Licensing during their inspections and/or visit. This is how we will continue to learn and grow.


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: It was determined that the operation does not have a treatment director.

Correction Narrative: The operation has hired a new TD.


summary: 748.505(b)(5) - Minimum qualifications for employees- Must have cleared pre-employment screening assessment.

raw_content: One of two records reviewed did not contain a pre-employment screening assessment.

Correction Narrative:
The Pre-Employee Reference Check will be added to the "New Hire Packet" to be completed once a prospective employee has passed the background check and has been offered a position at the Tree of Life RTC.
Please note that at Tree of Life RTC, we take pride in being compliant with Minimum Standards, the services we provide to the children we serve, and in caring for the staff that help us continue to be successful. We also appreciate the critiques and continued feedback that we receive from Licensing during their inspections and/or visit. This is how we will continue to learn and grow.


summary: 748.1217(b)(16) - Admission Assessment-At admission, must include determination of whether operation can meet immediate needs of child.

raw_content: Three of three records reviewed does not have a clear determination of how they will meet the needs of the children in care.

Category: Admission, Service Planning, Discharge

Correction Narrative: The operation emailed an example of how they will meet the needs of the residents: John will be provided with a safe and nurturing environment. He will receive three (3) meals a day to include a snack. He will receive Individual and group therapy weekly, monthly medication evaluation/management/monitoring, medical 3/30 as applicable and as the need arises, dental exams every six (6) months unless specified otherwise by the dentist, annual well-child exams, and vision management annually, educational assistance, therapeutic recreation, and daily life skills training. If applicable, family therapy will be provided upon request. Additional services will be provided if a child is received with special needs. (cardiology, orthodontist, psychiatrist evaluation, psychological evaluation etc.). This section will also reflect behavioral needs and/or medical/physical diagnosis and the recommendations from the CANS Assessment as well as the Psychological Recommendations. Please note that at Tree of Life RTC, we take pride in being compliant with Minimum Standards, the services we provide to the children we serve, and in caring for the staff that help us continue to be successful. We also appreciate the critiques and continued feedback that we receive from Licensing during their inspections and/or visit. This is how we will continue to learn and grow.


raw_content: The service plan reviewed did not have specific level of supervision.

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

Correction Narrative: The operation's administrator and treatment director will ensure that there is detailed documentation for awake and asleep hours.


summary: 748.885(3) - General pre-service training curriculum- Must include techniques and methods of administering medications.

raw_content: Staff did not have training for administering medication and no training for psychotropic medication.

Correction Narrative:
Corrective Action Plan received from Kimberly Bass at kimberly.basslpc@thepsychpro.com: Tree of Life RTC #1723466
Location: 19402 Bauer RD, Hockley, TX 77447-4241

748.885(3) General pre-service training curriculum- Must include techniques and methods of administering medications.
Staff need to have preservice training for administering medication before dispensing medications to children in care. Caregivers understand their most critical responsibilities prior to being solely responsible for a child in care. Basic entry-level knowledge of health and safety is essential to providing
All staff must receive preservice training for administering medication before dispensing medications to children in care. Caregivers understand and accept their most critical responsibilities prior to being solely responsible for a child in care. Basic entry-level knowledge of health and safety is assessed and determined by a medical provider to be acceptable to provide care by administering medications.
The Executive Director, LCCA, TOL Medical Provider complied by 12-08-2023
Attached Certificates and Training.


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

raw_content: Staff admitted they were not drug tested prior to starting position at the operation.

Correction Narrative:
Corrective Action Plan received from Kimberly Bass at kimberly.basslpc@thepsychpro.com: Tree of Life RTC #1723466
Location: 19402 Bauer RD, Hockley, TX 77447-4241
Arrival Date and Time: Unknown not listed
Departure Date and Time: Unknown not listed

745.4151(c)(4)(A) Mandatory drug testing-all applicants intended to be hired are subject to pre-employment testing, must have results prior to child access
Drug testing should be completed before the applicant has access to children in care as this is part of pre-employment screening.
12/08/2023
Drug testing must be completed with a 12-panel test indicating negative results, the results must be filed in all employee charts before being placed on the schedule; before any applicant has access to children in care as part of pre-employment screening.
The Executive Director LCCA


summary: 748.2101(6) - Medication storage & destruction-remove discontinued medication immediately & destroy it in a way that ensures children do not have access to it

raw_content: Expired medication was observed stored in the medication cart and not properly discarded. It was also noted the cart was full and expired medication were falling out.

Correction Narrative:
Plan of compliance received sent by Kimberly Bass kimberly.basslpc@thepsychpro.com
All medication must be discarded the same day it is discontinued and notify
Executive Director LCCA, TOL
storage & destruction-remove discontinued medication immediately & destroy it in a way that ensures children do not have access to it.
discarded properly to prevent harm to children due to children gaining access to and ingesting medications or other over the counter supplements.
the pharmacy medications are ready for pick-up to be properly destroyed. All discontinued medications are removed from the medication room, same day and stored double locked in the admin offices until the pharmacy picks them up to properly destroy and pharmacy signs for showing medications are received. Medication must not remain on TOL premises longer than 10 days to prevent harm to children due to children gaining access to and ingesting medications or other over the counter supplements.
Medical Provider, Case Manager/PLSP


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

raw_content: An active staff list was provided during the investigation inspection. A current employee that was hired on 11/21/2021 shows an inactive employment background check status since 08/25/2023.

Correction Narrative:
Therapist is now active as a contractor for Tree of Life RTC. All employees and contractors will be deactivated within 7 days of no longer being associated with Tree of Life RTC. The Employee Validation List has been validated as of 9/15/2023. Employee validation will be validated monthly and at any time an employee or contractor disassociates from Tree of Life
RTC. A background check was performed for Akbar H. and reflects that he is eligible to be a contractor for Tree of Life RTC. Please see attachment. An active background check will be performed for all employees and contractors of Tree of Life RTC, and monthly audits will be performed for all staff requiring background checks going forward.


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

raw_content: Several holes were observed in walls/closet during the walk through. In addition, an exposed electrically socket was observed in a downstairs bathroom.

Correction Narrative: All physical site issues have been fixed: Electrical socket has been pushed in and glued in place. All holes have been fixed please see pictures. RCCR Ashley Barnes completed an inspection at the facility on 10/17/2023 and noted the building was in good repair.


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: One of two employee records reviewed does not contain the correct proof of HS diploma or GED.

Correction Narrative: The operation provided a copy of the employee's diploma.


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

raw_content: One of two employee records reviewed is missing an affidavit.

Correction Narrative: The operation emailed a copy of the employee's affidavit.


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

raw_content: One of two records reviewed was missing the duration of placement, family involvement, and social history.

Correction Narrative: The operation emailed stating that they have created a clear step by step method/job aide for the case manager to use for every area of the child/youth's road map for treatment, services, and family connections is adequately covered.


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

raw_content: It was determined that the operation has been without an administrator for 90 days. The operation stated that they have two options that they will be sending an offer letter to by this week. Depending on which one accepts, the anticipated start date will be at the beginning of September.

Correction Narrative: The operation hired a full time administrator effective 11/10/23.


raw_content: During the walk-through, it was observed that a bathroom door was split open, one hole in the wall, one door has been kicked at the bottom, wooden rods in closet can be easily removed, electrical plug is not connected to wall, and one dresser was missing the drawer.

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

Correction Narrative:
Tree of Life will also be contracting out a maintenance/Handyman to ensure that all repairs going forward have a faster turn around.
Tree of Life has also implemented the DFPS Daily Grounds and Checklist for Staff to perform a maintenance and grounds check before the beginning of their shifts begin.


summary: 748.867(d) - Pre-Service Training Exemption-Document the applicable exemption factors in the appropriate personnel record

raw_content: One of three staff records reviewed indicated that he was exempt from pre-service training due to receiving it at previous employment. There is no documentation of these trainings being completed.

Correction Narrative: Tree of Life will screen all new employees for verification of pre-service trainings, if the employee cannot provide a training record or trainings to verify previous pre-service completion records, then that staff will be required to complete TOL Pre-Service Trainings.


summary: 748.1331(b)(2) - Preliminary Service Plan-For child receiving treatment services, include a description of child's immediate educational, medical, and dental needs

raw_content: One of five plans reviewed did not contain the possible side effects of the medication.,

Correction Narrative: Tree of Life will consult with the Pharmacist or Psychiatrist for all service plans for any possible side effects regarding each child's medication.


summary: 748.1217(b)(15) - Admission Assessment-At admission, must include child's understanding of the placement

raw_content: Five of five admission assessments reviewed did not provide a clear understanding of why the child was placed in your care.

Correction Narrative: Prior to acceptance of any child it will be required for the Case Manager to submit Verification of the reason each child is being placed with Tree of Life RTC


raw_content: Two of three staff records reviewed did not contain proof of graduating high school or college.

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

Category: Personnel

Correction Narrative:
Tree of Life Administrative/Personnel files will be randomly audited by the leadership team to ensure that all employee documents are submitted before any personnel is cleared to start.

All Staff will be required to show proof of a high school diploma or college transcripts before starting employment at Tree of Life RTC


summary: 748.1217(c)(8) - Admission Assessment-Prior to initial service plan, add child's criminal history, if any

raw_content: Four of five assessments reviewed did not indicate if the children had any criminal history.

Correction Narrative: Tree of Life Executive Director and Treatment Director will review all treatment plans and admission assessments prior to being approved.


raw_content: One of three staff records did not contain an affidavit.

Standard Number / Description: 748.505(b)(4) - Minimum qualifications for employees-Complete notarized Licensing Affidavit for Applicants for Employment form

Correction Narrative: Tree of Life Administrative/Personel files will be randomly audited by the leadership team to ensure that all employee documents are submitted before any personnel is cleared to start.


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

raw_content: One of three staff records reviewed indicated that they are using a TB test from 2019 when they started working here 12/2022. The employee has no previous history of working at a GRO/RTC/CPA.

Correction Narrative: All new Staff who do not have a TB skin test from working in a RTC setting within the last year will be required to have a new TB Skin Test. The employee no longer works for the agency.


summary: 748.125(c)(1) - Suicide Training-All caregivers and employees must complete at least one hour of annual suicide prevention training.

raw_content: Two of three employee records reviewed did not contain suicide prevention training.

Correction Narrative: Tree of Life will ensure to add suicide prevention training to our annual calendar immediately, and our administrative assistant will ensure to prioritize this training to be scheduled as the next upcoming annual training.


summary: 748.1217(b)(2) - Admission Assessment-At admission, must include description of circumstances that led to child's referral for substitute care

raw_content: Three of five assessments had the same information as to the circumstances of why the child was placed in care.


summary: 748.1331(b)(5) - Preliminary Service Plan-For child receiving treatment services, designate who will be responsible for meeting each of the child's needs

raw_content: Five of five plans reviewed did not have a designated person for each child.

Correction Narrative: Tree of Life has added a Designee Signature on the Admissions form for the person responsible to ensure each child's needs are being met.


summary: 748.1217(b)(16) - Admission Assessment-At admission, must include determination of whether operation can meet immediate needs of child.

raw_content: Five of five assessments reviewed did not provide determination of how the operation will meet each child's needs, just states that they can.

Correction Narrative: TOL will ensure to require on all assessments how we plan to meet the immediate needs of that specific child that reason going forward immediate need plans must be approved by Executive Director and Treatment Director.


summary: 748.4009(c) - General requirements-There must be emergency transportation available at all times

raw_content: The operation's vehicle has been in the shop for a week and there is no emergency vehicle available.

Correction Narrative: Tree of Life RTC will be purchasing an additional means of transportation next financial quarter for any emergency needs in the future.


summary: 748.1217(b)(3) - Admission Assessment-At admission, must include description of child's behavior, appropriate & maladaptive, behavior posing risk to self/others

raw_content: Five of five assessments reviewed does not have a description of the actual behaviors.

Correction Narrative: Tree of Life Executive Director and Treatment Director will review all treatment plans and admission assessments prior to being approved TOL will ensure to input on all assessments the description of the actual behaviors for each child.


summary: 748.1217(c)(6) - Admission Assessment-Prior to initial service plan, add child's school history

raw_content: Five of five assessments reviewed did not have the complete school history of each child. They also didn't include the reason child was removed or placed at previous homes or RTCs.

Correction Narrative: Tree of Life Executive Director and Treatment Director will review all treatment plans and admission assessments prior to being approved. TOL Treatment Director will ensure that each assessment has the child's complete school history and ensure that the reason the child was removed from the previous RTC is included.


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

raw_content: Five of five records reviewed did not contain a suicide screening.

Correction Narrative: Tree of Life will screen all new residents for the required suicide screening before completing intake. Case Manager will ensure that this is performed during each new intake.


summary: 748.1217(c)(7) - Admission Assessment-Prior to initial service plan, add child's history of other placements (admission and discharge dates, reasons for placement)

raw_content: The admission assessment did not contain the reason for previous placements.

Correction Narrative: The operation updated the admission assessment to include the history of previous placements. The updated admission assessment was provided.


raw_content: The admission assessment does not contain the child's behavior, why he is in placement, the address/phone numbers for child's caseworker and foster parents. The admission assessment also did not contain the child's behavioral levels while at school.

Standard Number / Description: 748.1217(b)(3) - Admission Assessment-At admission, must include description of child's behavior, appropriate & maladaptive, behavior posing risk to self/others

Correction Narrative: The operation updated the admission assessment to include all required components. The updated admission assessment was provided.


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: The treatment director is only present once a week at the operation. The treatment director needs to work at least 30 hours a week at the operation to meet the full-time status.

Correction Narrative:
The administrator provided the following schedule for the treatment director:
Monday through Friday 6 hours each day.


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

raw_content: The plan was not signed or dated by the Treatment Director.

Correction Narrative:
The administrator provided to the following corrective action plan:
It is the administrator's responsibility to ensure that the Treatment Plan and the 72 Hour Preliminary Service Plan has all the required signatures. Moving forward, Tree of Life RTC will continue working and striving to ensure all required Plans of Service are accurate and up to date to maintain unity amongst all partners involved to better assist with sustaining the best interest for the children we serve.


summary: 748.1437(4) - Discharge/Transfer Documentation-Must include copies of child's service plans while in operation's care for the past 12 months

raw_content: The discharge paperwork was missing the child's service plans for the last 12 months and the child's list of medications.

Correction Narrative: The operation updated the discharge form that includes the child's treatment plans for the past 12 months and there is also documentation space for a list of the child's medication. The updated discharge form was provided.


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

raw_content: The sink handle in one of the bathrooms was loose. A tool was observed being used to assist with operating a washing appliance. Two doors were observed with physical breaks and cracks. One bedroom dresser was observed with broken handles.  Multiple foundational issues were also observed.

Correction Narrative: The operation submitted pictures of the repairs that were made. The pictures show all physical site repairs were made and are in compliance.


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

raw_content: It was determined that the operation does not currently have an administrator.

Correction Narrative: The operation hired an administrator 1/1/23.


summary: 748.681(1)(B) - Caregiver qualifications-Must be at least 21 yrs old if all children in group are 13 yrs old or older

raw_content: It was determined that a caregiver was 20 years old working with children 13 years old and older.

Correction Narrative: The caregiver is no longer employed at the operation.


summary: 748.533(a)(5) - Child-care administrator-Can be administrator for two operations if the Operations are contiguous

raw_content: While working for Tree of Life, the administrator was also listed at another facility that was not contiguous.

Correction Narrative: The administrator is no longer employed at the operation.


summary: 748.3351(4) - Interior Space-provide bedrooms with at least one window with outside exposure to natural light

raw_content: The operation has a bedroom downstairs that has 2 windows however there is an office being built therefore there is no outside exposure to natural light.

Correction Narrative: The operation will do construction to ensure that the child has natural light from their bedroom.


raw_content: One of the two records reviewed did not include the history of other placements, neonatal history, criminal history, school history, or skills/special interest

Standard Number / Description: 748.1217(c)(7) - Admission Assessment-Prior to initial service plan, add child's history of other placements (admission and discharge dates, reasons for placement)

Correction Narrative: The operation emailed an updated copy of the child's service plan that included all required information.


summary: 748.1217(b)(8) - Admission Assessment-At admission, must include child's current developmental, educational and behavioral level of functioning.

raw_content: One of two records reviewed did not include the child's current level of functioning.

Correction Narrative: The operation provided an updated copy of the child's plan including all required information.


summary: 748.1209(c)(1) - Child Orientation - Include information on how to make complaints to outside agencies

raw_content: It was determined that the orientation provided did not include how to make complaints.

Correction Narrative: The operation emailed a correction stating that the orientation packet has been updated to include information for the residents to know to make complaints if needed.


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

Correction Narrative: 748.2151(d) Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home mode	Three of eight medication logs did not have the accurate count of medication administered.		All medication passers have been reminded of the importance of keeping an accurate and daily count of the medications and log.  A refresher medication training will be completed on 7/8/2022 for all medication passers.  A copy of the training certificates will be forwarded to Ms. Lodrig once completed.


summary: 748.915(b)(5) - Pediatric CPR training documentation must include the expiration date of the certification determined by the organization providing the certification

raw_content: During inspection, it was noted that a CPR Certificate of a staff did not contain an expiration and/or renewal date as determined by the organization providing the certificate.

Correction Narrative: Trainer Dr. Victor Keys has corrected the CPR and First Aid Certificates to include the training hours and expiration date. Each certificate has been filed in the employee binder.  The LCCA will ensure all future certificates include what's needed according to the Minimum Standards.


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

raw_content: During inspection, it was noted that the discharge plan of 1 child did not include the name, address, telephone number, and relationship of the person to whom the child is discharged.

Correction Narrative: The Discharge Plan has been updated and filed with the child's discharged documents.  All future discharge documentation will include the name, address, telephone number, and relationship of the person to whom the child is discharged to.


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

raw_content: During inspection, it was noted that the Health and Sanitation permit for the operation has expired and needs to be renewed.

Correction Narrative: The Health and Sanitation Inspection was completed on 5/2/2022.  To avoid future deficiencies; the Director has set a reminder on his cellphone and calendar to schedule all inspections at least 2 months in advance of the due date.  A copy of the inspection has been placed in the inspection binder.


summary: 748.941(a)(4) - Training Criteria- Must include a certificate, letter, or a signed and dated statement of successful completion from the training source.

raw_content: During inspection, it was noted that the training log for one staff did not contain a certificate, letter, or a signed and dated statement of successful completion from a training source on trainings held for the year 2021.

Correction Narrative: The current administrator Angie Bacon was hired on 3/29/22.  A certificate cannot be created before her hire date.  However, as of 3/29/22 all employee files will contain a training log and a certificate of training from the training source.


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

raw_content: During inspection, it was noted that 2 out of 2 children's files reviewed did not contain an initial/updated service plan.

Correction Narrative: The Initial and Service Plan review has been completed and filed in the child's record.  As of 5/3/22 the LCCA will ensure that each child record will include an Admission Assessment, 72-hour, Initial, and Service Plan review(s).


summary: 748.4003(1)(B) - General requirements-When transporting a child the operation must ensure each driver is covered by automobile insurance

raw_content: During inspection, it was noted that there was no copy of the car insurance of the operation's vehicle.

Correction Narrative: The operation emailed a copy of the insurance and insured that they will keep a copy of it in the vehicle.


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

raw_content: One of two records reviewed did not contain a notarized affidavit.


summary: 748.885(3) - General pre-service training curriculum-Includes techniques and methods of administering medications if caregiver administers psychotropic meds

raw_content: One of two records did not contain documentation of training for the administering of medication.


summary: 748.105(2) - Personnel Policies - Develop written job descriptions including minimum qualifications and job responsibilities for each position

raw_content: One of two records reviewed did not contain a job description. The one job description reviewed needs more information in regards to the employee position.


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

raw_content: The locks on the window in a child's room is broken. Door handle missing on one door.


summary: 748.363(7) - Personnel records - Include statement signed and dated by the employee that he has read a copy of the operational policies

raw_content: One of two employee records still does not have a signed copy of the operational policies.


summary: 748.3239(d) - Evacuation-Must document fire and severe weather drills, including date, time, type of drill, and length of time for evacuation/relocation

raw_content: There was no documentation about the severe weather drills.


summary: 748.4653(a)(1) - Pre-Service Training- All caregivers must receive 8 hours of general pre-service training before being only caregiver responsible for a child in care

raw_content: There is no documentation regarding pre-service training for one of two employee records reviewed.


summary: 748.1381(2) - Service Plan Review-If child receiving treatment services for ED, ASD, or PMN, review at least 90 days from date of last service plan

raw_content: The child's service plan was not updated.  The last service plan made available was dated 8/9/2021.


summary: 748.685(b)(5) - Caregiver responsibility - when deciding how close to supervise, takes into account the child's physical, mental, emotional, and social needs

raw_content: Staff failed to appropriately supervise a child in care.  The child has been involved in several accounts of physical and verbal aggression incidents.  Staff have not taken into account the child's mental, emotional and social history and have not been able to prevent the incidents involving this child.


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

Correction Narrative: 748.4653(a)(2) Pre-Service Training- All caregivers must receive 16 hours of EBI training, if operation prohibits EBI then 8 hours only.	It was determined that the caregiver was not properly trained in EBI.	5/13/2022	The caregiver(s) involved are no longer employed at the operation.   All other staff have completed an 8-hour CPI Refresher Course on 4/25/22.


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: Caregivers failed to adhere to the child's rights to be free of abuse, neglect, and exploitation as defined in Texas Family Code Section 261.001.

Correction Narrative: The caregivers involved are no longer an employee of the operation.   All other staff have completed the Abuse and Neglect online training.  In addition, all staff will receive an instructor led training on Preventing, Identifying, and Reporting Suspected Abuse, Neglect, and Exploitation training on 5/31/2022.  Once completed a copy of the training certificates and sign-in sheet will be sent to CCR Ms. Lodrig.


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

Correction Narrative: 748.2461(b)(3) Short Personal Restraint-Caregiver may not use restraint that obstructs child's airways or impairs child's breathing	It was determined that a caregiver placed a child in a chokehold.5/11/2022. The caregiver(s) involved are no longer employed at the operation. All other staff have completed an 8-hour CPI Refresher Course on 4/25/22.


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

Correction Narrative: 748.507(1) Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks	It was determined that a caregiver placed a child in a chokehold and slammed him against the wall, hitting the child's head. The child was not provided with medical care and has a history of a traumatic brain injury.	The caregiver(s) involved are no longer employed at the operation. All other staff have completed an 8-hour CPI Refresher Course on 4/25/22.


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

Correction Narrative: 748.311 Serious Incident Documentation-Documented in written report.	It was determined that there was no serious incident report documented. 	5/13/202 The caregiver(s) involved are no longer employed at the operation. All other staff have completed a 2-hour Documentation- Progress Notes and Serious Incident training on 4/29/22.


summary: 748.2301(c) - Disciplinary Measures-goal must be to teach a child acceptable behavior and self-control; caregiver must explain reason for discipline when imposed

raw_content: It was determined that the caregiver did not use appropriate disciplinary measures.

Correction Narrative: The caregiver(s) involved are no longer employed at the operation. All other staff will complete a 1-hour instructor led training in TOL Discipline Policies and Procedures on 5/31/22. Once completed a copy of the training certificates and sign-in sheet will be sent to CCR Ms. Lodrig.


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

raw_content: It is determined that the administrator was not working full-time at the operation. She was working another job as a CPS Investigator.

Correction Narrative: The operation has hired a new administrator that started two weeks ago.


raw_content: One of two employee records did not have a signed copy of the operational policies.

Standard Number / Description: 748.363(7) - Personnel records - Include statement signed and dated by the employee that he has read a copy of the operational policies


raw_content: The window in the back bedroom does not have locks.

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