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

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


state: TX

facility_name: Empower Youth Homes LLC

summary: 748.121(2) - Abuse and neglect policy-Methods for employee awareness regarding child abuse/neglect, including signs that a child may be a victim of abuse/neglect

raw_content: The policy lack's methods for employees to recognize signs that a child may be a victim of abuse/neglect.

Category: Organization and Administration

Standard Risk Level: Medium High

Corrected at Inspection: No

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


summary: 748.105(3)(C) - Personnel policies-develop professional staffing plan that documents staffing patterns/ratios/hours of coverage/plans for backup caregivers

raw_content: The appropriate ratios for a Residential Treatment Center are not listed this policy. The policy provided states one staff to eight residences when it should be one staff to five residences.

Standard Risk Level: Medium


summary: 748.121(3) - Abuse and neglect policy - Methods for increasing employee awareness of prevention techniques for child abuse and neglect

raw_content: The policy lack's prevention techniques.


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

raw_content: Not all beds in the operation contained all components required for linens on the beds.

Category: Physical Site

Correction Narrative: All beds were observed to have proper bedding.


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

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

Category: Safety and Emergency Practices


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

raw_content: The hot water was not working.

Standard Risk Level: Medium Low

Deficiency Narrative: The hot water was not working.

Correction Narrative: The hot water was observed to be working properly.


summary: 748.113(6) - EBI Policy - Post EBIs permitted at your operation viewable to children/clients and provide them with a personal copy of EBI policies

raw_content: The policy does not indicate that permitted EBI will be posted or provided to children.


summary: 748.1205(a)(2) - Admission Documentation-Includes court orders establishing who is the managing conservator for the child, if applicable

raw_content: Admission assessment is missing a spot for the primary caregivers for the child, any person with whom the child is allowed to leave the operation, and any other individual who has the legal authority to consent to the childs medical care.

Category: Admission, Service Planning, Discharge

Corrected at Inspection: Yes


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

raw_content: The staff file reviewed did not have a TB test.

Category: Reports and Record Keeping

Correction Narrative: Copy of TB test was received.


summary: 748.113(9)(B) - EBI policy - A child/adult client/resident because someone on behalf of the client files a complaint, provides information relating to misuse of EBI

raw_content: The policy does not mention that retaliation is prohibited if a complaint is filed.


summary: 748.3475(a)(5) - Safety Requirements-The administrator or designee must inspect the equipment and surfacing material for tripping hazards and other hazards

raw_content: Bedroom 1 has a tripping hazard at the doorway.

Correction Narrative: A "watch your step" sticker was placed at doorway of Bedroom 1.


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

raw_content: The policy does not mention Simultaneous Intervention.

Category: Emergency Behavior Intervention


summary: 748.113(5)(A) - EBI policy - For orientation, explain and document to a child in a manner that the child can understand

raw_content: The policy does not include sharing information with children in a manner the child can understand.


facility_name: Jamsteld West Community Living - Ellie's House

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

raw_content: Ground had two propane tanks out in the open backyard. Storage building was tore down by wind.


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

raw_content: All beds did not have a mattress protector on them.


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: An unauthorized leave of absence was reported past the 6-hour required timeframe.

Category: Individual Standards Evaluated

Correction Narrative:
Moving forward, abuse and neglect hotline will be called in accordance minimum standards.
The facility Operations Manager will be responsible for contacting the hotline in accordance with standards. Incident reporting standards will be posted in staff office for quick reference


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

raw_content: During a review of medication storage, it was found that a child's medications were prepped, were all kept in a small clear container but not administered due to the child being hospitalized.

Correction Narrative: Follow up was conducted and documentation was obtained.


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

raw_content: A child service plan was not completed within the required timeframe.

Correction Narrative: As per the Treatment Director, the operation has implemented calendar reminders as well as frequent reminders in treatment meetings about the completion of service plans regardless of child participation.


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

raw_content: Two out of two medication count was not accurate or true. The quantity of medication was 90 out of 90 however the system only had qty of 30 with 9 already administered.

Category: Medication

Correction Narrative: Add additional note in electronic medication system that shows additional prescribing physicians name. Child had just been discharged from inpatient hospital and new prescribers name was not on discharge medication record.


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

raw_content: Two of two records do not show who prescribed the medication.


summary: 748.1209(d) - Child Orientation-document in child's record when orientation occurred, any required information omitted, reason for any omissions

raw_content: 5 out of 6 files did not have required documentation in the children in care's file.

Standard Risk Level: Low

Correction Narrative: The administrator will conduct bi-weekly audits and create a checklist to ensure all required documentation is available upon request. The operation will also have selected personnel during all shifts be responsible for checking the checklist and ask for required documentation not provided at the time of admission to the appropriate personnel.


summary: 748.1331(d) - Preliminary Service Plan-Document the plan in the child's record

raw_content: 5 out of 6 files does not have the required documentation in the children in cares files.


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

raw_content: Fire inspection expired on 03/2025.

Deficiency Narrative: Fire inspection expired on 03/2025.

Correction Narrative: Operation got fire inspection completed on 03/03/2025. The operation also added their annual inspections to their outlook calendar to ensure the inspection is completed annually and to submit a copy to HHSC Residential licensing once completed.


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

raw_content: Validation was not completed as of 05/06/2025.


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

raw_content: Operation is not completing monthly checks on fire extinguishers as operation admitted this is not being completed and was not able to provide documentation to show completed.

Correction Narrative: Administrator created a weekly walkthrough checklist to ensure staff walks through and checks all fire extinguishers. Administrator will conduct a bi-weekly audit to ensure all walkthroughs are completed. All staff will be trained on requirements by administrator.


facility_name: Hearthstone Support LLC

summary: 748.939(c)(4) - Training criteria-Training includes a certificate, letter, or a signed and dated statement of successful completion from the training source

raw_content: Documentation verifying completion of required suicide prevention training was not available for staff.

Correction Narrative:
A current training certificate in suicide prevention was emailed to inspector for the remaining employee involved in this investigation completed 03/07/26. The agency provided this corrective action via email:
-The facility conducted an immediate review of all staff training files to identify missing documentation.
-Staff members without documentation on file were required to submit proof of completed suicide prevention training or complete the training again.
-Copies of all training certificates have now been placed in the appropriate personnel binders accessible for licensing review.
-Program director will review training records monthly to ensure all required training documentation is complete and up to date.


summary: 748.125(d)(4)(E) - Suicide Screening- Must be administered immediately if the child exhibits warning signs that necessitate a suicide screening be conducted.

raw_content: A suicide screening was not administered after a child in care was observed with self-inflicted injuries.

Correction Narrative:
The following corrective action was sent via email:
The facility reviewed its Suicide Prevention and Risk Assessment Policy with all direct care staff.
All staff will receive refresher training on suicide prevention protocol, including recognizing self-harm indicator, when suicide screenings must be conducted and proper documentation procedures


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

raw_content: A child in care self-harmed on 01/15/26 and was admitted into a behavioral hospital on 01/16/26. This incident was not reported to Licensing until 01/20/26.

Correction Narrative:
The following corrective action was sent via email:To prevent recurrence, the facility has implemented the following measure:
	Staff Training
o	All clinical, direct care, and supervisory staff will receive training on incident reporting requirements, including incidents involving harm and hospitalization.
	Incident Reporting Protocol
o	A standardized incident reporting checklist has been implemented to ensure licensing notification occurs within required timelines.
	Supervisory Oversight
o	All serious incidents will now be reviewed by the Program Director or designee within 24 hours to confirm that licensing notifications have been completed


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

raw_content:
The following was missing from the serious incident report:
-Name of the operation, physical address, and phone number.
-The name, age, gender, and date of admission of the child or children involved.
-The names of all adults involved and their role in relation to the child(ren).
-The names or other means of identifying witnesses to the incident, if any.
-Interventions made during and after the incident, such as medical interventions, contacts made, and other follow-up actions.
-The treating licensed health-care professional's name, findings, and treatment, if any.
-The resolution of the incident.

Correction Narrative: As suggested, the operation shall begin using HHSC Form 2991 when documenting serious incidents.


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

raw_content: Bedroom #1 that is currently occupied by 1 child did not have handsop nor paper towel/towel for hand washing and drying.


raw_content: 1 out of 3 child records was missing proof of child orientation and required signature.

Standard Number / Description: 748.1209(d) - Child Orientation-document in child's record when orientation occurred, any required information omitted, reason for any omissions

Correction Narrative:
On 11/14/2024 the operation submitted corrections through email regarding their plan to maintain compliance with minimum standards.

The operation has now added Resident Orientation and Handbook to their admission checklist to ensure all residents receive their orientation and sign their acknowledgment during the required timeframe dictated by the minimum standards. The correction plan and admission checklist are uploaded in the document library.


facility_name: Tomorrow's Promise Youth Home LLC

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

raw_content: A staff member's personnel file contained a job description requiring the employee to be 21 or older. The employee was under 21 years of age, and the job description listed the position as Youth Care worker rather than Administrative Assistant.


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

raw_content: Two youth's files were reviewed and were missing required elements such as circumstances that led to the child's referral, child's behavior, level of care, legal status, type of admission.

Correction Narrative:
Received a corrective action plan via email from the operations administrator stating the following:
Tomorrows Promise Youth Home, LLC will ensure that information provided from the case worker and the common application will be provided in all service plans detailing the need for the placement.


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 missing the following information: the age, gender, and date of admission of the child who was absent, the time the unauthorized absence was discovered, how long the child was gone or if the child did not return, the name of the caregiver responsible for the child at the time the childs absence was discovered, the intake report number, if a report was made to Licensing or the Department of Family and Protective Services and whether law enforcement was contacted, including the name of any law enforcement agency that was contacted and the number of the police report.

Correction Narrative: Received a corrective action plan with an unauthorized log with required information that was originally missing. Tomorrow's Promise Youth Home Administration Team will ensure that unauthorized absence documentation includes required information per standards.


summary: 748.1205(a)(14) - Admission Documentation- Includes the results of the suicide screening at admission, if required.

raw_content: During a review of records, a youth in care had high risk behaviors listed in their admission assessment which necessitated a screening to be conducted. The results were not included in the youth's file.

Correction Narrative: Received a corrective action plan from the administrator via email. The corrective action plan stated the following: Tomorrows Promise Youth Home LLC will utilize either Ask Suicide-Screening Questions (ASQ) and/or Columbia- Suicide Severity Rating Scale (CSSRS) toolkits, resources, support clients impacted by suicide, preventions and postvention strategies. Tomorrows Promise Youth Home LLC policy is based on current statistic and evidence based according to Texas Suicide Prevention (texassuicideprevention.org) and the American Foundation for Suicide Prevention(afsp.org).


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

raw_content: During an inspection, it was found that a youth was transported in a non-agency vehicle that did not display a current registration sticker.

Category: Transportation

Correction Narrative: Recieved a corrective action plan from the administrator stating the following : Tomorrows Promise Youth Home LLC will have a vehicle available to transport client, pick up supplies and for Adopted program business to include medical, dental and vision care, behavioral health services, school and school programs, family visits, court hearings, and any other services necessary to fulfill the clients plan of service. Tomorrows Promise Youth Home LLC is committed to safe, accident-free driving. Every Tomorrows Promise Youth Home LLC employee has to be Adopted to drive the company vehicles as a part of their employment. They are responsible for its safe operation and condition; a worker is considered to be at work while driving their personal vehicle if they are carrying out a task authorized by Tomorrows Promise Youth Home LLC and recording their mileage. Employee vehicles, when accompanied by a Tomorrow's Promise Youth Home LLC resident must be insured, meet state vehicle inspection and operating requirements, and must still practice safe driving.


summary: 748.1271(5) - Emergency Admission Documentation-Include known contraindications to the use of restraint

raw_content: During a review of a youth in care's emergency admission assessment. It was noted that the documentation did not include any of the required information listed.

Standard Risk Level: High


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

raw_content: Four employees' files reviewed did not contain the Form 2912, Pre-Employment Affidavit.

Category: Personnel

Correction Narrative: Received updated Form 2912's from operation's permit holder for all employees' files that were reviewed and missing the document.


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

raw_content: An employee's file that was reviewed and hired on October 1st. Did not include any details that the employee's prior employers were contacted.

Correction Narrative: Received an updated Pre-Employment Screening Template from the operation's permit holder via email for an employee's file that was reviewed. At the time of review the employee's prior employers had not been contacted. The Template now shows that the employee's prior employers were contacted.


facility_name: Prestige Homecare

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

raw_content: The incident report did not include the date of admission or the date of birth of the child.

Correction Narrative: The agency sent me their corrective action plan. Changes were made to personnel and the administrator will provide more oversight when it comes to documentation. Compliance will be monitored at their next monitoring inspection.


summary: 748.1215(b) - Admission Assessment-Professional level service provider must sign & date assessment, which must be in child's record

raw_content: The admission assessment reviewed was not signed and dated by a professional level service provider. The record was also missing the child's last name.

Correction Narrative: Information in question will be updated, and Prestige has made a change in personnel to ensure documentation is accurate and submitted. Treatment Director and Case Manager will receive additional training by Executive Director in this process to ensure compliance in this area. Job tasks have been reassigned.


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

raw_content: The incident reports reviewed did not document the name of the operation, the operation's phone number, child's age, child's date of admission, child's gender, the staff's role, and if the legal parent was notified.

Correction Narrative: The operation has made a change in personnel to ensure documentation is accurate and submitted in a timely manner. Direct Care staff also will receive additional training by Executive Director and Administrator in this process to ensure compliance in this area.


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

raw_content: During the walk through of the operation's backyard there is sinkhole observed. It is also observed that there were some concrete squares that would pose as tripping hazards.


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

raw_content: During the walk through of the operation is was hot water shower knob in the top bathroom was broken. The house has ac door enterances accessible to children. The closets in the rooms do not have working lighting.


facility_name: Safe Haven, RTC LLC

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: During the inspection of employee records, it was determined that the employee was missing reference checks.

Correction Narrative: Received the reference check via email


summary: 748.105(6) - Personnel Policies - Develop written policies on whether caregivers may take children away for day/overnight visits, ensure policy meets requirements.

raw_content: The operation was missing 748.685(e) from their policy. The operation submitted an updated policy during the inspection.


summary: 748.105(8) - Personnel Policies - Ensure employees report serious incidents and suspected abuse/neglect and exploitation directly to DFPS

raw_content: The operation was missing a statement regarding delegating the responsibility and the need for notification or obtaining approval to make a report to the hotline. The operation did submit updated policies to reflect this requirement during the inspection.


summary: 748.1209(b)(13) - Child Orientation-Include internal grievance procedures

raw_content: The operation child orientation handbook was missing grievance and complaint procedures. The operation did submit updated handbook with grievance policies and procedures.


summary: 748.117(2) - Transitional living policy - Supervision of participants consistent with 748.1019 and 748.1021

raw_content: The operation policy was missing supervision in regards to transitional living program. The operation updated their policy during the inspection.


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

raw_content: During the walk-through, it was noticed that there were no first-aid kits at the operation. The operation came into compliance by producing first aid kits and storing them in an accessible location for employees.


summary: 748.117(3) - Transitional living policy - Expected behaviors of participants and consequences for failure to comply

raw_content: The operation policies were missing the expected behaviors and consequences of the children in the program. The operation updated their polices during the inspection.


facility_name: The Ark Residential Treatment Center, LLC

summary: 748.105(4)(C) - Personnel policies-develop professional staffing plan that documents staffing patterns/ratios/hours of coverage/plans for backup caregivers.

raw_content: Staffing plan was requested and the operation was not able to provide it.

Correction Narrative: The Owner submitted a new staffing plan with additional details on hours of coverage, staffing patterns, backup staffing plan, and awake supervision.


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

raw_content: It was found the Administrator quit on 11/10/25, but was stil active as of 12/4/25.

Correction Narrative: The former administrator, Mr. Vincent Harper, now has an inactive background check as of 12/09/25.


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

raw_content: Operation does not have a full-time administrator.

Correction Narrative: The operation has officially hired an administrator with a hired date of 08/01/2025. Staff has been added to administrators position and controlling person.


summary: 748.361(a) - Personnel records - All active records maintained at the operation

raw_content: No staff files were present during the inspection.

Correction Narrative: Staff will ensure all files are always present at the operation in the locked cabinet. Staff will conduct weekly audits to ensure all files are present at the operation.


facility_name: Hunting For More Love, RTC

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

raw_content: The operation failed to report to Licensing the hospitalization of a child within 24 hours.

Correction Narrative:
**Corrective Action Plan  Investigation #3197388**

**Rule Cited:** 748.303(a)(2)(A)  Reporting Serious Incidents

**Statement of Understanding:**
The operation understands the requirement to report all serious incidents to Child Care Regulation within 24 hours, regardless of whether another entity (such as a school or third party) has already made a report. Timely reporting ensures proper oversight and compliance with licensing standards.

**Corrective Actions to Be Implemented:**

1. **Clarification of Reporting Responsibility**
   Effective immediately, the operation will ensure that all serious incidents are reported directly to Licensing by designated staff, even if the incident has already been reported by another party. The operation will no longer rely on third-party reporting to meet this requirement.

2. **Staff Training and Retraining**
   All administrative staff and caregivers responsible for incident reporting will complete refresher training on serious incident reporting requirements, including timelines and documentation procedures, by 4/3/26.
   New staff will receive this training during onboarding.

3. **Updated Internal Procedures**
   The operation will update its written policies to clearly state that all reportable incidents must be submitted to Licensing within 24 hours by the operation itself. These procedures will include step-by-step guidance on how and when to report.

4. **Incident Reporting Log Implementation**
   An internal tracking log will be maintained to document all incidents, including the date/time of occurrence, date/time reported to Licensing, and the staff member responsible. This will ensure accountability and timely compliance.

5. **Administrative Oversight**
   The Director or designee will review all incident reports daily to confirm that any reportable incidents are submitted within the required timeframe.

**Plan for Monitoring Compliance:**
The Director will conduct weekly reviews of the incident log for the next 60 days to ensure compliance with reporting timelines. Ongoing monitoring will continue thereafter as part of regular operational oversight.

All corrective actions will be fully implemented by 4/3/2026.

Keyosha Hunter


summary: 748.1703(b) - Menus-must document food substitutions on the menu that are of comparable food value

raw_content: Observation of a menu change and nothing documented and speaking with the Administrator it was determined when an item is changed then it has not been documented.

Category: Child Care

Correction Narrative: An email was received from the Administrator on 11/10/25. The email had a compliance plan attached and it stated that the operation updated their meal substitution log. The operation also trained staff on menu substitution protocols, and the menus will be audited weekly by the dietary manager.


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

raw_content: Review of the discharge summary showed medications were not listed.

Correction Narrative: An email was received from the Administrator on 11/10/25. The email had a compliance plan attached and it stated that the operation reviewed all current discharge and transfer forms to identify any missing information. A new discharge/transfer form was created to include medication information.


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

raw_content: The van used to transport children does not have liability insurance.

Correction Narrative: An email was received from the Administrator, Keyosha Hunter, on 10/20/25 with the liability insurance attached for her personal vehicle, that she stated is the only vehicle being used to transport children currently during a phone call also conducted on 10/20/25.


summary: 748.2259(a) - Psychotropic medication documentation-Maintain a daily record of the child's use of psychotropic medication according to requirements in 748.2151

raw_content: Medication logs reviewed for Brody's two prescribed medications (Lisderamfeta (am) and Risperidone (pm) revealed several missing dates.  There is no entry for the am medication for 7/16, 7/20, 7/27, 8/10, 8/11.  There is no entry on the pm medication for 7/15, 7/16, 7/26, 7/27, 8/7 and 8/9.   There is no explanation for any of the missed entries.  Of the incident reports submitted, only 1 indicated a medication refusal.  There were also 2 instances in which the morning medication was administered at 3pm and 10pm without any explanation.

Correction Narrative: Operation provided a new medication log with an additional space to notate if a child is AWOL, refuses medication, etc so that there are no missing dates.  The log also contains a legend to identify each code.


raw_content: Based on a review of the information, it was determined that an adolescent in care sustained an injury that warranted treatment by a medical professional; however, the incident was not reported to Licensing within required timeframe.

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

Correction Narrative:
07/16/2025-The LCAA submitted to licensing staff via email the operation's Corrective Action Plan indicating the LCCA will ensure that all staff complete a retraining on Serious Incident protocols by July 25, 2025.
The LCCA will maintain staff training certificates on file and make them available for review at Licensing's request.


facility_name: Boys Haven Of America

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

raw_content: A child's dental appointment is past due as of 5/9/23.

Correction Narrative:
5/29/23: Child's dentist appointment has been set for June 1st at 3:00 pm.
6/1/23: Child discharged from facility.


summary: 748.509 - TB screening-Caregivers, employees, volunteers, contract service providers screened for TB before having contact with children in care

raw_content: A staff member that has been on shift has not had a tB screening.

Correction Narrative:
5/29/23: Staff went and had her TB test done but was not able to have it read due to her being sick. She is not on the schedule and will not be until the test is complete.
6/1/23: Children were discharged from the facility.
6/16/23: There are no staff at the facility.


summary: 748.930(a)(3) - Annual Training- Caregivers at cottage home must have 20hrs annual training.

raw_content: A staff's training is past due for DFPS Trauma Informed Care and DFPS Recognizing and Reporting Child Abuse.

Correction Narrative: Training completion certificates were received from the Administrator via email for staff in question.


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

raw_content: A child's medication and medication record was altered during an unannounced inspection at the operation, to portray compliance.

Correction Narrative: 9/5/23: Per the ED Amanda Diaz, "As far as compliance with these matters is concerned, at this time, there are currently no residents or direct care staff on campus."


summary: 748.2103(b) - Medication Destruction-Discontinued or expired meds & meds left at facility destroyed by health-care professional/pharmacist or LCCA & adult witness

raw_content: A child's single-loose pill was observed in a zipped bag in the desk drawer of an administrative staff.


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

raw_content: Staff allowed a child to ride his bike outside while staff stayed indoors and when a random car approached the child, the staff chose to not to go outside to intervene but record the exchange between the child and the person in the random car while staying inside the cottage, potentially leaving the child at immediate danger.

Correction Narrative: Per CM Patricia Planas, "as far as our compliance with these matters is concerned, at this time, we do not have any residents on campus or any direct care staff to be able to correct this action."


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

raw_content: Staff did not act prudently when not searching a child upon watching him make a potential drug transaction on campus. Administration did not act prudently when waiting a full day to call LE to assist with the incident, when waiting 2 days to search the child and their belongings, when waiting several weeks to drug test the child even after smelling smoke of an illegal substance in their room, and when not providing any level of discipline for having illegal substances at the facility.


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

raw_content: Medication records are not being logged accurately, as a child and 2 staff recall a DCS administering medications, but the log was completed as administered by the Director.


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

raw_content: Twice in May 2023 a child's medication record was not appropriately logged. Medication record on 5/11/23 indicated that meds were administered on 5/11/23 but was not logged onto the record until 5/17/23. Medication record on 5/18/23 indicated that meds were administered on 5/18/23 but was not logged onto the record until 5/19/23.


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

raw_content: Based on information gathered during interviews as well as a review of operation records, it was determined staff utilized abusive and/or profane language towards an adolescent in care.

Correction Narrative:
On 06/20/2023, Boys Haven Assistant Executive Director/LCCA submitted a Corrective Action Plan via email to licensing staff.

According to the Corrective Action Plan, the staff was written up for the action.  Additionally, the staff was refreshed on Behavior Management techniques by reviewing TBRI (Trust Based Relational Intervention) which is based on three principles, Connecting, Empowering and Correcting.  Appropriate consequences were discussed with staff as well.

Currently, Boys Haven does not have staff or residents.  The operation's last resident left on 06/02/2023 as well as all staff last day was on 06/16/2023.


raw_content: A referral was received by Residential Contracts to inform CCR that during a visit on 4/5/23, a medication log was observed to have a missing signature to show who had given a medication. During that same visit, the operation corrected the missing signature by having a particular staff sign the form. CCR cited the operation for this, but because this form was "corrected," at the inspection, the follow-up compliance date was dated 4/5/23. Several days later, the operation disclosed that the person who signed the medication log was not the one who gave the medication. The operation then had another staff sign the form and this form was sent to Residential Contracts.

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

Correction Narrative: It was confirmed through casebook that the correct person's name was listed; however, it wasn't completed on the paper form. This has been corrected.


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

raw_content: A medication log dated 4/3/23, for the medication Doxycycline Hyclate 100MG, was missing the staff's signature/initials who administered the medication. This was observed by Heightened Monitoring - Residential Contracts during a visit on 4/5/23. The operation corrected the missing information prior to end of the HM Contracts visit.

Correction Narrative:
4/11/23: The operation corrected the information during the HM visit on 4/5/23.
4/21/23: The operation disclosed to Residential Contracts several days after this citation that the person who signed the form to show it was "corrected" on 4/5/23 was not actually the staff who administered the medication. The corrected staff signature was documented and shared with Residential Contracts on 4/18/23. Due to this new information, the follow-up compliance date will be changed from the original date of 4/5/23 to 4/18/23.


summary: 748.535(2) - AP Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.

raw_content:
During a review conducted on March 24, 2023, it was
determined that:
(1) the Administrator failed to ensure compliance with the current HM Plan; and
(2) 12 months had elapsed since the effective date of the plan.
The heightened monitoring plan for this operation included a specific planned end date at the
12-month mark by which the operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase
of post plan monitoring. As a direct result of the administrators failure to ensure timely compliance with the heightened monitoring plan, this operation is
now unable to successfully move to post-plan monitoring. Furthermore, the operations planned end date must now be revised, and the period of heightened monitoring must be extended. Further details of the administrators failure to ensure
compliance include the following:
- Operation failed to satisfy the conditions of the plan
- Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and
- Operation was unable to meet compliance with Medium-High or High weighted licensing citations.

Correction Narrative: An HM extension was approved effective 3/27/23.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your GRO in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 748.535(2). The HM deadline for your operation has been extended by 6 months and the new deadline is September 28, 2023.


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

raw_content: A medication log for Hydroxyzine documents the medication was given at "8:6." The accurate time is missing from the log. This was observed during a visit by HM Contracts on 3/21/23.

Correction Narrative: The operation sent a photo of the medication log with an updated time of 8:16pm.


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

raw_content: A therapist transported and supervised children in a private vehicle on a fishing trip without a qualified caregiver present.

Correction Narrative:
A corrective action was received on 05/19/2023 from the operation staff stating the following: A background check was completed and cleared for the therapist on 4/27/2023. All outings of a similar nature will have staff accompany the residents.
DFPS has terminated the contract with the operation. All children were removed by 5/26/23.


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

raw_content: The contract therapist transported children in a private vehicle and supervised children on a fishing trip as group therapy sessions without any operation staff present. The therapist did not have a BGC at the operation and would have required one due to the therapist's role changing from therapist present at the operation in official capacity to volunteer functioning in the role of a caregiver.

Correction Narrative:
Contract therapist BGC verified in CLASS as submitted and cleared. An email was sent from the executive director to rccr staff on 05/19/2023 stating the following: A background check was completed and cleared for the therapist on 4/27/2023. All outings of a similar nature will have staff accompany the residents. I have attached his documentation for your review.
DFPS has terminated the contract with the operation.


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 discovered through interviews with children in care that staff member has been observed sleeping during their night shift on two occasions.

Correction Narrative: Staff will work in pairs during the overnight shift in order to hold each other accountable for providing awake supervision. Youth will be checked on every fifteen minutes and documented in the bed check log. All overnight staff will be retrained in how to provide bedtime supervision and bed checks. There will also be random pop ups by admin done throughout the month whether in person or by reviewing the cameras located in the living areas.


raw_content: Guanfacine and Carbamazepine were administered to a child in care on 2/7/23; however, staff did not document the dosage or the date and time it was given. This was observed by Contracts during a visit the same day.

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

Correction Narrative: Staff responsible was verbally reprimanded and the staff admitted that she was rushing when administering the medication and should slow down. Medication error reports were completed and submitted to CCR.


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

raw_content: A child was unable to take Guanfacine on 2/5/23 and 2/6/23 because there were no refills available. The operation's attempts to have the medication refilled by contacting the doctor and pharmacist were unsuccessful. The operation should have contacted Star Health for assistance with this issue, as they were directed to do on 1/19/23 during a meeting with Heightened Monitoring.

Correction Narrative: The operation informed CCR that if a similar situation arises in the future that they plan to contact Star Health for assistance.


summary: 748.2151(c)(7) - Medication record - must include the child's refusal to accept medication

raw_content: A child in care refused to take Qelbree on 2/1/23 and 2/2/23 and refused to take Bupropion and Escitalopram on 2/2/23. There was no documentation on the medication record to reflect this.

Correction Narrative: The staff responsible was verbally reprimanded for the incident. The refusals have since been documented. Medication error reports were submitted to CCR.


raw_content: During an HM visit on 1/11/23, it was observed that a child's Metformin medication was not administered the evening of 1/7/23 as required. A child's Omeprazole AM medication shows it was last administered on 1/10/23 and after this, it required a refill. This medication was not refilled, and the child did not receive it on 1/11/23, as required.

Standard Number / Description: 748.2003(b)(5) - Administration of prescription medication-Ensure the child has taken the medication as prescribed

Correction Narrative:
Staff member is being given a corrective action for his part in missing the administration of the medication. A MIR was not written by staff but was written by Admin upon the error being found on 1/11/23.
The Omeprazole was prescribed in November for a 68-week period. The prescribing physician did not intend for the medication to be refilled. A refill request was called into the pharmacy on 1/4/23. On 1/6/23 the pharmacy stated that he had no refills, and they were contacting the doctor. During a conversation with the NP 1-13-23 she stated this upon receiving the request for a refill from both us and the pharmacy. On 1-13 she prescribed a refill for as needed for 1 month then to use an over-the-counter medication after that time frame.


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

raw_content:
Medication errors for the following incidents were not documented within the required time frame:
- Bupropion HCL XL 300 MG - AM dose missed on 1/11/23
- Omeprazole - AM dose missed on 1/11/23
- Metformin - PM dose missed on 1/7/23
- Guanfacine - Missed doses on 1/4/23 - 1/6/23

Correction Narrative:
Medication Incidents Reports were not written by staff. MIR's were written on 1/11/23 at 6:30pm by Admin for all 4 instances.
All staff will be retrained on Medication Incident Reports and the reasons for writing them by 1/27/23.
The Omeprazole prescription ended on 1/10/23. It should have been documented that the medication was complete. We will continue to try to get more information about the need for the prescription and how long residents are intended to be on them if they are not maintenance medications.


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 an HM visit on 1/11/23, a medication (Bupropion HCL XL 300 MG, AM dose) shows a remaining count of 12; however, the medication log shows a remaining count of 11. On 1/10/23, this AM medication is documented as being administered twice and on 1/11/23, the AM medication is not documented as being administered at all.

Correction Narrative:
An error was made by staff when she marked the line item with the wrong date and the failed to punch out the medication and give it to the resident. A MIR was written on 1/11/23 by admin.
This staff member was given a corrective action and very apologetic for her mistake that resulted in the error of the resident not receiving the medication in a timely manner.


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

raw_content: During an HM visit on 1/11/23, there was no medication log available for a child's medication (Pro-Air).

Correction Narrative:
A medication log is created upon the introduction of a new medication to the resident. The log must have been misplaced or fallen out of the medication book.
A new log was completed on 1/11/23 upon finding that there was not one in the book.


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

raw_content: During walkthrough, bathroom number two had a rusted shower rod, rusted towel rack, and a crack in door. Bathroom number 1 had a rusted towel rack.

Correction Narrative: A picture was emailed of the cracked door being repaired and the towel rack and shower rod being replaced.


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: Upon reviewing one child's record, there was no TB documentation.

Correction Narrative: A picture of the child's TB results was emailed.


raw_content:
During a review conducted on 9/23/2022, it was determined that:
(1) the Administrator failed to ensure compliance with the current HM Plans; and
(2) 12 months had elapsed since the effective date of the plan
The heightened monitoring plans for this operation included a specific planned end date at the 12-month mark by which the operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of post plan monitoring.  As a direct result of the administrators failure to ensure timely compliance with heightened monitoring plans, this operation is now unable to successfully move to post-plan monitoring.  Furthermore, the operations planned end date must now be revised, and the period of heightened monitoring must be extended.
Further details of the administrators failure to ensure compliance include the following:
- Operation failed to satisfy the conditions of the plan
- Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and
- Operation was unable to meet compliance with Medium-High or High weighted licensing citations.

Standard Number / Description: 748.535(2) - AP Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.

Correction Narrative: An HM extension was approved effective 9/23/2022.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your GRO in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 748.535(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is 3/24/2022.


raw_content: In 1 of 2 child records reviewed, there were medication errors that were not documented in the childs record; from 05-17-22 to 08-25-22.

Standard Number / Description: 748.2203(c) - Medication Error-Operation must meet documentation requirements within 24 hrs

Correction Narrative: Operation submitted medication error forms that was missing along with a refresher course training on medication management.


raw_content: 2 of 2 safety plans did not include ten minute checks as noted to be completed. On three separate days, 15 minute checks were documented. Also, there was no names on the forms used.

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: RCCR Inspector Tracy received an emailed from Shantle Foster-Asst. Administrator, that included an updated room check log that the operation will use.


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

raw_content: The required information of name, age, date of admission, and gender of the of the other child involved in an incident was not listed on one serious incident report reviewed.

Correction Narrative: An email was sent to rccr staff on 08/04/2022 of an additional incident report of the other child involved in the incident.


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: One serious incident reviewed was missing the required follow-up/interventions  on the incident report.

Correction Narrative: An email was sent to rccr staff on 08/04/2022 of the incident report to reflect the changes made with the details added that were left off.


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

raw_content: The operation has been without a qualified full time Licensed Child Care Administrator since March 5, 2022.

Correction Narrative: The operation hired an administrator effective 7/18/22. Verified in CLASS system the administrator position has been filled and verified the administrator's license is current.


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

raw_content: There was no serious incident report completed to review during the inspection for 1 of 2 residents, for an incident that occurred on 06-12-22. 1 of 3 serious incident reports reviewed during the inspection did not include all the requirements. The EBI report did not include the de-escalation attempts before and during the use of the EBI and the child's reaction to the strategies, the names of any witnesses to the EBI, including any child witness, the action of the caregiver took to facilitate the child to return to normal activities following the end of the intervention and the length of time the child was restrained.

Correction Narrative: Amanda Diaz-Business Manager emailed RCCR Tracy Robinson dated 07-08-22, a document that included the de-escalation attempts before and during the use of the EBI and the child's reaction to the strategies, the names of any witnesses to the EBI, including any child witness, the action of the caregiver took to facilitate the child to return to normal activities following the end of the intervention and the length of time the child was restrained.


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

raw_content: The child file reviewed emergency behavior intervention report did not include the Supervisor's signature.

Correction Narrative: Amanda Diaz-Business Office Manager emailed RCCR Tracy Robinson a document that noted that SIR and EBI reports will be signed by supervisory staff within 72 hours of the incidents on 07-08-22.


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

raw_content: 2 of 2 child's file admission assessment was not completed timely.

Correction Narrative: RCCR received an email dated 07-10-22 from Amanda Diaz-Business Office Manager that included 2 completed Admission assessments to satisfy the citation received from inspection #3889166.


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

raw_content: The emergency behavior intervention report for the child file reviewed did not include all the documented requirements. The EBI report did not include the de-escalation attempts before and during the use of the EBI and the child's reaction to the strategies, the names of any witnesses to the EBI, including any child witness, the action of the caregiver took to facilitate the child to return to normal activities following the end of the intervention and the length of time the child was restrained.

Correction Narrative: Amanda Diaz-Business Office Manager emailed a EBI report that included the required documentation to RCCR Tracy Robinson on 7-8-22.


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

raw_content: The child file reviewed during the inspection medication log was not documented accurately. The time the medication was given to the child was not documented as well as the amount remaining was documented incorrectly.

Correction Narrative: Amanda Diaz-Business Office Manager emailed RCCR Tracy Robinson n 07-08-22, a document from the staff meeting held on 06-20-22 that included a refresher training on medication documentation.  Robinson.


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

raw_content: During the inspection, a child's medication was not stored properly.


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

raw_content: There was no serious incident post discussion completed for the child file reviewed during the inspection.

Correction Narrative: The post discussion document was emailed to this inspector this date by Amanda Diaz-Business Manager.


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

raw_content: Four of four child records reviewed did not document the required known contraindications.

Correction Narrative: An email was sent on 07/19/2022 with the child's admissions assessments.


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

raw_content: Two of four child records reviewed did not document the reason for placement on the placement agreement.

Correction Narrative: An email was sent on 07/19/2022 with the child's placement agreements.


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

raw_content: 1 out of 3 staff records reviewed did not have the required test results for the TB test.

Correction Narrative: Operation submitted the employee's completed test results.


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

raw_content: Two of three staff records reviewed did not have a signed job description.

Correction Narrative: Operation submitted signed job descriptions for both staff.


raw_content: Four of Four child's admission assessements reviewed was missing significant required information.

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


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

raw_content: The operation has not begun to maintain an annual unauthorized absence summary log.

Correction Narrative: An annual unauthorized summary log for the year of 2022 was sent via email on 06/15/2022 to rccr staff.


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 three staff files reviewed did not have the required high school diploma or high school equivalency in the record.

Correction Narrative: An email was sent to rccr staff on 07/15/2022 of the staff's high school diploma dated as of May,2017.


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

raw_content: Four of Four child records reviewed were observed to be missing significant information/documention to include  therapy notes, psychotropic medication reviews, medication logs, medical and dental documention, and  psychological evaluations.


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

raw_content: 1 of 3 staff records reviewed did not have the required signed affidavit in the record.

Correction Narrative: Operation submitted the staff member's completed affidavit, completed on 6/24/22.


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

raw_content: One of four child records reviewed did not have the required orientation documentation in the child's record.

Correction Narrative: An email was sent to rccr staff on 07/15/2022 with an orientation form listing topics covered during the orientation signed by the child and the child's case manager as of 07/15/2022.


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

raw_content: Four of four child's records reviewed, the initial service plans were overdue and the service plan meetings have not been scheduled nor conducted.

Correction Narrative: An email was sent to rccr staff on 07/26/2022 with the completed child's service plans.


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

raw_content: The operation does not have a qualified full time Licensed Child Care Administrator.


summary: 748.313(3)(B) - Serious Incident child absent without permission-document notice to parents and law enforcement about child's absence and subsequent location/return

raw_content: Two serious incident reports reviewed during the inspection did not include the date and time the operation notified the parent(s) and the appropriate law enforcement agency or the names of the persons spoken with regarding the child's absence.

Correction Narrative: RCCR Tracy Robinson received an email from Keri Jeasonne-Boys Haven Program Director dated 6-10-22 that included confidential reports for two children that addressed and satisfied citation from inspection #3884423.


summary: 748.303(e)(3)(A) - Serious Incident-Report to Licensing no later than 24 hours after awareness if an adult contracts a reportable communicable disease

raw_content: A staff member tested positive for Covid, exposing eight children in care. The operation did not submit a report to Licensing and did not document a serious incident report.

Correction Narrative:
Op submitted the report to hotline re: PD staff testing positive for communicable disease.
E-Report Confirmation Number: 6fdf8a64
Report regarding testing positive for COVID reported to the hotline on 6/8/2022.
Intake 2892503


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

raw_content: During the inspection, a serious incident report that involved a AWOL child (inspection 3879356) was not available for review. A subsequent incident on a different date, involving 2 other AWOL children was not available for review.


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

raw_content: The child's file reviewed admission assessment was not completed timely.

Correction Narrative: Keri Jeansonne-Program Director, provided an email dated 06-06-22, that included the corrective action for ensuring that admission assessments be completed timely.


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

raw_content: During the inspection, an ex employee who resigned on 05-13-22, was listed on the People's List in CLASS.

Correction Narrative: Keri Jeansonne-Program Director, provided an email dated 06-06-22, that included the corrective action for ensuring that employees that are no longer with the operation be removed from the People's List.


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

raw_content: It was determined that a staff member at the operation would use profane language in front of the children.

Correction Narrative:
Boys' Haven follows our employee handbook and Policy and Procedures using progressive discipline for staff. Depending on the severity of the issue, staff will receive a verbal warning (1st offense), written reprimand (1st/2nd offense), suspension while investigating, or termination of employment.

The staff involved in the investigation incident is no longer employed with Boys' Haven.

Going forward, incidents involving a staff member subjecting a child to abusive or profane language disciplinary actions will include a written reprimand and a required De-Escalation training as well as notice to loss of employment if the actions were ever repeated.


summary: 748.455(c) - Unauthorized Absence-debriefing must be documented in childs record, including routine activity that would be inappt for child to return to and why

raw_content: It was determined that the operation did not document the unauthorized absence debriefing that was conducted once the children returned to the operation.

Correction Narrative:
The operation has created a document, along with a serious incident report that shows an Incident Debriefing. The form reflects asking the child what happened, where did they go, why they left, and the plans going forward.

A copy of the debriefing has been uploaded into sharepoint.


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

raw_content: It was determined that the operation did not call law enforcement to report an unauthorized absence of a child within the required time frame as set by minimum standards.

Correction Narrative:
The Serious Incident Report has been adjusted to include a line that that requests Date & Time of Return as well as the lines where licensing and police must be called within the 6 hour window and places for staff to write in the time.

Executive Director attached an updated SIR to reflect the new changes to the document. Document has been uploaded into SharePoint


summary: 748.313(3)(E) - Serious Incident -Unauthorized absence of a child if child returns to op after 24 hrs document as addendum to report documenting childs return

raw_content: It was determined that the operation did not complete an addendum to the original serious incident report documenting the child's return to the operation.

Correction Narrative:
After a child returns from an unauthorized absence, we will conduct a debriefing and fill out the Addendum to Serious Incident Report.

Executive Director also attached an SIR Addendum to show that the operation has


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

raw_content: It was determined that the operation did not report to licensing the unauthorized absence of five children from the operation within the required time frame as set by minimum standards.

Correction Narrative:
The Serious Incident Report has been adjusted to include a line that that requests Date & Time of Return as well as the lines where licensing and police must be called within the 6 hour window and places for staff to write in the time.

Executive Director attached an updated SIR to reflect the change in reporting to licensing within six hours.


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

raw_content: It was determined that the operation did not document the length of time that the child was gone from the operation in their serious incident reports.

Correction Narrative:
The Serious Incident Report has been adjusted to include a line that that requests Date & Time of Return as well as the lines where licensing and police must be called within the 6 hour window and places for staff to write in the time.

Executive Director also attached a new copy of the Incident Report to show that the report has been updated to reflect the change. Document is uploaded into SharePoint


summary: 748.949(b)(2) - Annual Training Documentation-Includes date of the training

raw_content: During the inspection, one staff SAMA certificate did not include the date the training, the number of hours provided and the trainer's qualifications.

Correction Narrative: RCCR Tracy Robinson received an email dated 05-20-22, from Keri Jeansonne-Program Director with an attached completed SAMA certificate for Trayvante Maxson-Direct care staff.


raw_content: During the inspection, a serious incident report that involved a AWOL child was not available for review.

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


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

raw_content: During the inspection, the child file reviewed did not contain the preliminary plan.

Correction Narrative: The Preliminary Service Plan for Daniel H. was provided to RCCR Inspector-Tracy Robinson at HM inspection, which was reviewed and met satisfaction to address the concern.


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

raw_content: During the inspection, the citation provided on 03-02-22  inspection, regarding the child's service plan was not addressed.

Correction Narrative: RCCR staff-Tracy Robinson received an email from Keri Jeansonne-Program Director at Boys Haven that contained a Service Plan for the child.


raw_content: One child record did not have correct dates for the last annual medical visit and next due date. There was no documentation regarding plans for high school completion, post secondary education and training and no documentation to address the child's trauma triggers, nor discussions with the child regarding sexually transmitted diseases and human reproduction.

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


summary: 748.931(a)(1)(B)(iii) - Annual Training-Every 6 months a caregiver must complete at least 4 hours of training in EBI

raw_content: During the inspection, 1 staff file did not complete EBI training timely.

Correction Narrative: Mekisha Wright-Executive Director, that included corrective action. The Program Administrator will ensure that staff annual training of Emergency Behavior Intervention training is completed every 6 months from the date when staff last received the EBI training to ensure completion in a timely manner.


summary: 748.2953(b) - Evaluation-Operation's quarterly data on emergency behavior interventions must be reported to Licensing quarterly

raw_content: The quarterly emergency behavior intervention report was not submitted to licensing within the required time frame.

Correction Narrative: The EBI report was completed on 02/17/2022 and verified by rccr staff. The administrator sent an email stating the report was completed.


summary: 748.2003(b)(7) - Administration of prescription medication-maintain documentation provided by health-care professional on the administration of current medication

raw_content: It was determined the operation failed to ensure the prescription was issued from the pharmacy with the correct dosage instructions per the prescription received from the prescribing doctor and then ensuring that it was on the med log correctly.

Correction Narrative: The operation has sent via email a new plan of medication management. Form will be uploaded into Digital Storage.


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

raw_content: During the walk through of the cottage, food in the fridge and pantry were observed to be minimal, however, the locked back pantry, refrigerator, and freezer were observed to be fully stocked. Some food items were observed to be expired.


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

raw_content: A child's service plan documents sexually aggressive behavior, however, there are no plans to address safety.

Correction Narrative:
An email was sent to rccr staff on 03/04/2021 stating the following:
I am resigning as of today.  I have informed the on coming Program Director that when a resident have high risk behaviors this must be discussed with staff and the administrative treatment team.  This will also need to be discuss during initial service plan meetings.  A plan will be set in place to help prevent the high risk behaviors of residents and it will be indicated in the child's service plans.
A meeting was held with the president and the new program director on 03/08/2022 by rccr and technical assistance regarding this standard was given while going over the citations in this investigation.


summary: 748.1339(a)(1) - Initial Service Plan-Service planning team must include at least one of the child's current caregivers

raw_content:
The service plans for 2 youth were completed without conducting service planning meetings, nor including the youth, a caregiver, or managing conservator.
Administrative staff disclosed not having sent the required notifications nor having scheduled the service planning meetings.
Two child records had no documentation of service planning meeting notifications.

Correction Narrative:
An email was sent to rccr staff by the former administrator stating the following:
I am resigning as of today.  I have informed the on coming Program Director that the caregiver need to be involved in initial service planning.
A meeting was held with the president and the new program director on 03/08/2022 by rccr and technical assistance regarding this standard was given while going over the citations in this investigation.


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

raw_content:
20 Medication Administration Records were reviewed. A child had 5 incidences of missing a dosage and there were no corresponding medication error records. The child had another 8 incidences of missing a dosage (those were documented in a medication error). The child also went without one of the medications for 2-3 days due to the operation not refilling the medication timely.
Another client in care didn't began taking one of the prescribed medications until 7 days later after the medication was prescribed. One of the clients medication was discontinued by the doctor and the client was still being administered the discontinued medication.

Correction Narrative:
An email was sent to rccr staff from the former administrator stating the following: I am resigning as of today.  I have informed the Board Director Member and the on-coming Program Director that each child must take the prescribed medication.  I went over the medication checklist with the Board Member  and Program Director (form attached). I  created a medication checklist to help prevent medication from running out and to get prescriptions called in on time.
The medication checklist was sent via email by the former administrator.
A meeting was held with the president and the new program director on 03/08/2022 by rccr and technical assistance regarding this standard was given while going over the citations in this investigation.


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

raw_content: 7 of 18 Medication Administration Records reviewed did not document the reasons for the prescription medications.

Correction Narrative:
An email was sent to rccr staff on 03/04/2022 from the former administrator stating the following: I am resigning as of today.  I have informed the on coming Program Director that each medication log must be filled out completely, including why the medication was prescribed.
It was confirmed by the president and the program director that the administrator did go over the medication log forms with them during the meeting with rccr staff on 03/08/2022.


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

raw_content: 12 of 18 Medication Administration Records reviewed did not include the prescribing physician's name.

Correction Narrative: An email was sent to rccr staff on 03/04 from the former admistrator stating the following: I am resigning as of today.  I put a plan in place for the oncoming staff.  I reviewed the medication log with the new Program Director, and informed her on how to fill out the form with the prescribing health care professional name.  It was confirmed by the president and the program director that the administrator did go over the medication log forms with them.


summary: 748.931(a)(2)(A) - Annual Training-Caregivers in an operation that provides a certain amount of treatment services must complete 50 hrs

raw_content: A staff at the operation does not have required trainings. The staff was identified as a "med tech" and is at the facility for limited hours each week; however, the staff is not a contractor, but an employee of Boys Haven.

Correction Narrative: Mekeisha-Executive Director verbally confirmed that Rebecca Davilla is no longer employed at the operation.


raw_content: 2 of 2 children's records reviewed did not list the children's high risk behaviors on the initial service plan or the review service plan and thier was no documentation of plans to address either of the child's behavior's in the plan.

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

Correction Narrative: An email was sent to rccr staff stating for future references, the assessment team will thoroughly check the completed, initial service plan being sure that every section is filled out correctly and completely and the placement documents as well as the psychological will be reviewed for any high risk behaviors.


summary: 748.1337(b)(1)(N) - Initial Service Plan-Include signatures of service planning team members that were involved in development of service plan

raw_content: 2 of 2 service plan reviews that were reviewed were missing the following:did not have all of the required signatures, didn't have all the participation dates, and didn't have the all the dates the plans were shared.

Correction Narrative: An email was sent to rccr staff stating for future references, the admissions assessment team will be sure that all required signatures and dates of all required parties are obtained, as well as the dates were shared.


raw_content: 1 of 2 child records reviewed preliminary plan was  not completed within 72 hours.

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

Correction Narrative: An email was sent to rccr staff stating for future references the admissions assessment team will ensure the required preliminary service plans are completed within the 72 hour time frame.


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

raw_content: 2 of 2 child records reviewed did not have the name of the designated persons listed, and thier were no face sheets on either of the child's records.


summary: 748.1539(b) - Immunizations-The operation must maintain current immunizations records for each child in care, including any exemptions or exceptions

raw_content: 1 of two child records reviewed did not have the required immunization record in the child's file. 2 of 2 child's records reviwed did not have the required tb test in the child's record.

Correction Narrative: An email was sent to rccr staff stating for future references, the child's record will include documentation showing where the child received the required test. The child is no longer present at the facility that the citation relates to.


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 annual fire inspection is not current and determined to be overdue.

Correction Narrative: An email was sent to regulation staff on 11/03/2021 showing the operations most recent fire inspection conducted on 10/25/2021 with violations, therefore a re-inspection was scheduled for 11/08/2021. The LCCA stated the fire inspector didn't come out on 11/08/2021 and stated she is still waiting on the fire inspector to conduct the inspection. The LCCA stated all corrections has been made that was in violation on the fire inspection form. An email was sent to rccr staff with a fire re-inspection conducted on 12/16/2021 without any violations.


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

raw_content: 1 child medication log form showed that the child was not administered a dose of medication and their is no reason or medication error documented in the binder.

Correction Narrative: An email was sent to rccr staff stating moving forward: A Medication training guidebook has been created for staff with the goal of decreasing medication errors. A Designated Staff (program administrator and/or training coordinator will check medication logs weekly to ensure the forms are being filled out correctly.


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

raw_content: The required annual health inspection is late and determined to be overdue since the last health inspection was conducted at the facility.

Correction Narrative: An email was sent to rccr staff of the updated health inspection conducted as of 10/21/2021.


summary: 748.1341(b) - Initial Service Plan-Child's record must include documentation of advance notice to parents of planning meeting and any responses from the parents

raw_content: 2 of 2 child records reviewed did not have the required documentation of the advance notification of the service planning meeting.

Correction Narrative: An email was sent to rccr staff stating for future references, the child's record will include documentation showing where the parent was notified and any documentation of responses from the parent prior to the child's service plan. The children are no longer present at the facility that the citation was regarding.


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

raw_content: 1 of 2 child's records reviewed showed one child's service plan to be associated with another child which indicates that the child the plan was created for was based on the other's child's information.The child the plan was created for shows to have identified as receiving ID treatment, but the child doesn't actually recieve the services.

Correction Narrative: An email was sent to rccr staff stating for future references, the admissions assessment team will be sure that all service plans are uniquely created to fit each individual resident, being sure that all are, current, true, and accurate. The children are no longer present at the facility that the citation was regarding.


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

raw_content: 1 of 2 child's records reviewed intial service plan was not completed within the required time frame.

Correction Narrative: An email was sent to rccr staff stating for future references the admissions assessment team will ensure the required intial service plans are completed within 45 days of admission.


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

raw_content: During the inspection, the Business Office Manager did not have a background check submitted or cleared prior to being allowed to be present at the operation.

Correction Narrative: Phone call with LCCA regarding BGC for the staff. Verified online, BGC was submitted on 9/15/21, employee BGC is active, with standard provisional conditions. -LG


summary: 748.3931(1) - Weapons, firearms, explosive materials, and projectiles-handguns are not permitted

raw_content: During the inspection, a knife was observed on a  child's bed.


summary: 748.3397(d)(1) - Bathing-Provide showers and bathtubs with hot & cold running water under sufficient pressure to meet the demands of children

raw_content: The shower was not working in room #1 of the Steinhagen Cottage.

Correction Narrative: During the HM inspection, the shower in room #1 was observed to be working properly.


facility_name: Christs Haven For Children

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

raw_content: The caregivers were not available when a child attempted suicide.

Correction Narrative: A meeting was condutced with houseparents on 2/11/26 concerning appropriate supervison, changes to the home and saftey plan.


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

raw_content: The caregivers did not follow the child's service plan according to the supervision requirements and discipline techniques.

Correction Narrative: On 1/14/2026. the director sent an email with a summary of the meeting conducted with the house parents, director and administrator. The meeting took place on 1/12/26. Service plans, supervision and discipline were discussed with all. This was also discussed over the phone with the director and RCCR Inspector.


raw_content: An employee's son lives at the operation and does not have a background check.

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


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

raw_content: One cottage out of eight cottages had all three fire extinguishers with an expired date. The tags documented the date of September 2023.

Correction Narrative: The director sent a copy of the three fire inspections completed on 10/10/24. A copy of the receipt was also provided. They are now updated.


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 out of two children files reviewed did not complete the TB test for the child in care.

Correction Narrative: The director sent a copy of the TB test for the child. The director also informed RCCR Inspector that the operation staff had a meeting on 10/10/24 regarding the issue and plan to calendar with any placement under 1 year old their TB test on the day of placement, along with a reminder one week in advance. A case manager will do the calendaring and the director will review.


summary: 748.363(8) - Personnel records - Include a Pre-Employment Affidavit for Applicants for Employment as specified in Texas Human Resources Code §42.0563

raw_content: One out of two files reviewed for staff were required to have form 2912 completed but did not.

Correction Narrative: RCCR Inspector received a copy of the form 2912 completed for the employee. The director also stated that they are working on updating their checklist for employees to ensure the form 2912 is included.


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: One out of the two files reviewed did not have documentation that a drug test was completed.

Correction Narrative: The director sent a copy of the drug test and results for the staff member missing in the file. The director also updated the checklist for the requirements in the staff files. A copy of the results and checklist were uploaded.


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

raw_content: There was a box of dish pods and lighter fluid accessible to children. During the inspection, the foster parent placed all the items in a locked closet, inaccessible to the children.


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

raw_content: The service plan was not specific to the child in care.

Correction Narrative: Director sent an updated copy of the child's service plan. The plan addressed more specific details about the child and how the caregivers with supervise the child in the home and out of the home. A copy has been uploaded.


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

raw_content: One out of two staff files reviewed did not have a high school diploma to document that the staff person qualified for their position.

Correction Narrative: The operation provided a copy of the staff's high school diploma.


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: The debriefings for the three unauthorized absences did not document all the required information.

Correction Narrative: A new form was crated to ensure all information is proved for the debriefing. A copy was provided. Staff attending training on April 24, 2023 to discuss the form.


summary: 748.3273(8) - First Aid Kits-Each one must contain thermometer

raw_content: There were three cottages that did not have a thermometer, four cottages that did not have tweezers and two cottages that did not have scissors in their first aid kit.

Correction Narrative: All first aid kits were observed to now have the missing items in the kits. The kits are now complete and will be checked monthly.


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

raw_content: One out of twelve fire drill reviewed and two out of twelve severe weather drills reviewed were not conducted within 6 months of the last drill.

Correction Narrative: Drills will be conducted every five months. Staff attended training on April 24, 2023 about the change.


summary: 748.3931(a)(3)(D) - Weapons and ammunition must be separately stored and locked.

raw_content: Cottage 4 did not have the ammunition locked.

Category: Recreation Activities

Correction Narrative: The ammunition was observed to locked properly. Photo was taken. They will be checked monthly.


raw_content: One of the two child files reviewed did not have the tuberculosis screening.

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

Correction Narrative:
RCCR Inspector received a copy of the child's TB test for the child. Inspector reviewed the doctor's visit record conducted on 5/3/23 for the TB test. It was conducted as an X-ray screening. The operation received a copy of the final results on 5/8/23. The results were negative. A copy has been uploaded.

RCCR Inspector spoke with administrator on 5/1/23. Child was taken to doctor and unable to receive TB test. Child was sick at the time of appointment.


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

raw_content: On 6/15/2022 a child in care sustained an injury that required medical treatment. This was not reported to licensing until 7/5/2022.

Correction Narrative: The operation provided all direct care staff additional in-person training on the minimum standard requirements for reporting serious incidents to statewide hotline/licensing. The operation's administrator obtained the signatures of all staff that received the training and provided the documentation to licensing for review.


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

raw_content:
Two staff files did not have proof TB test results.

This was corrected during the inspection.


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

raw_content:
Out of the four employee files reviewed, no files had an employee job description.

This was corrected at the inspection.


facility_name: Meridell Achievement Center

summary: 748.1007(b)(1) - Child/caregiver ratio-Awake caregiver may care for 15 children if any child in group requires treatment services

raw_content: Overnight staff interviewed stated the operation has been out of ratio multiple times overnight in the last 2 months.

Correction Narrative:
Interviews were completed with children in care regarding overnight ratio.
Additionally, the census and staffing schedules were pulled for 2 random days this week showing the operation has been in compliance.


summary: 748.1553 - Child must be immediately treated by health prof, contact emergency svs or take child to ER for injury/illness requiring treatment by a health prof.

raw_content: During the investigation, it was determined that a child sustained a head injury while playing basketball and showed symptoms of a concussion at 2:15 PM. Despite earlier instructions from a doctor that the child needed emergency room treatment, the child was not taken to the ER until 9:37 PM

Correction Narrative: Interviews were completed with children in care regarding medical care. Children questioned had needed medical care at one point while placed and confirmed they received it timely.


summary: 748.2307(4) - Other Prohibited Punishments-using sarcastic or cruel humor, and verbal abuse

raw_content: A caregiver used inappropriate language to a child in care referring to their self-inflected wound scars, in addition to other comments about children's bodies and religion.

Correction Narrative:
Interviews were completed with children in care regarding language and comments of staff.
Additionally, documentation of training was received and reviewed. Language and interactions with patients was covered in the unit meeting in January. Individual correction action and coaching was given to the staff involved.


raw_content: A child's injury and ER visit was reported to the hotline late.

Correction Narrative:
An email was received from the Administrator on 1.5.26. The following was explained-
All units have been provided with an orange binder that has reporting guidelines, timelines, and requirements listed per Minimum Standards.  Director of Nursing will review those guidelines again with nursing team to ensure that all notifications and reports are being completed as per Minimum Standards. The nurse will notify the on-call administrator of any incident that requires reporting to the TDFPS hotline based on the guidelines in the orange folder. The administrator on call will direct the nurse to make the hotline report and provide the information of the report to the AOC so that the AOC can forward the report information to the risk management team/Campus Administrator of Meridell.


raw_content: During the course of the investigation, it was determined that a child in care sustained a fracture during recreational activity. However, the child had to wait 24 hours before being fully evaluated by a medical professional.

Standard Number / Description: 748.1553 - Child must be immediately treated by health prof, contact emergency svs or take child to ER for injury/illness requiring treatment by a health prof.

Correction Narrative:
Inspection form 4091282
Follow-up inspection with the Program Director at Meridell, and the Medical Director of Meridell. The nurse involved was counseled and retrained on 11/4/2025 by the Director of Nursing.


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

raw_content: Interviews confirmed a child reported this incident to a staff but the child was not listed on the Serious Incident Report. There was also another victim involved but this child was not listed. Only one of the staff involved were listed on the Serious Incident Report.

Correction Narrative:
An email was received from the operation on 12.18.25. It was explained nurses will continue to be trained in ensuring that all parties are listed on the incident report (staff and patients). This was discussed with the Director of Nursing and Program Director so that training and guidance could be set up.
Additionally, Risk Management Team continues to review the IRs and will work alongside the nursing team to ensure that if there is missing information that the information is completed before final submission of the report is approved.


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

raw_content: Review of the background checks found a staff left in Nov 2025 but was still active as of 12/10/25. This was also verified by interviews that were conducted.

Correction Narrative: An email was received from the operation on 12.15.25. It was explained the citation was staffed with the DON, Program Director, and CEO. The operation is in the process of hiring a new Human Resources Director. Nursing and program leadership has been made aware they are to notify HR immediately when staff is no longer employed to ensure the 7 day timeframe is met.