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

raw_content: A staff member was left alone during awake hours, and did not adhere to the safety plan.

Correction Narrative: Children and staff were interviewed and confirmed that there are two staff at all time at the operation.  The safety plan will remain in place.  The safety plans are located in a book that is available for all staff. The staff also signs that they have read each child's plan that they understand it.


state: TX

facility_name: Independence Farm

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

raw_content: The caregiver did not report an incident to the hotline within the timeframe required.

Category: Individual Standards Evaluated

Standard Risk Level: Medium High

Corrected at Inspection: No

Correction Narrative: The staff that were interviewed confirmed that there was a staff meeting on 12/23/24 that the Administrator went over reporting and they had to complete the reporting training again.


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

raw_content: The caregiver did not provide adequate supervision when the children were engaging inappropriate activities.

Standard Risk Level: High

Correction Narrative: The children indicated that they are not left alone or unsupervised.  The staff confirmed that there are two staff to ensure there is a caregiver at all times with the children.


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

raw_content: One medication log did not have the staff signature that administered the medication.

Category: Medication

Standard Risk Level: Medium

Correction Narrative: An email was received from the Administrator indicating that immediately 05/13/24 the staff were retrained on the importance of signing their name on the medication log.  In addition, the staff now have to go through the medication logs within 2 hours to recheck.  In addition, the House Supervisor will also be checking the mediation logs to ensure for accuracy.


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

raw_content: There was not a shower door/curtain on the lower level shower.  The children were having to using the shower on the main floor, which is not where their bedrooms are located.

Correction Narrative: I received an email from the Administrator indicating that they have purchased a new shower curtain and installed it. A picture was sent with the shower curtain installed.


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

raw_content: A staff person was "horse play and rough housing" with the children in care and an injury occurred.

Correction Narrative: Staff were trained on appropriate play with the children.  Children were interviewed and confirmed that they no longer allowed to horseplay with staff.


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

raw_content: Two incident reports did not have the age and gender of all children involved.  In addition, the following was also missing.  All witnesses were not listed, as well as the resolution of the incident was not document.

Correction Narrative: The Administrator sent an email stating that the staff were individually proper trained on how to document serious incident reports. An attachment with the incident report form was sent ensuring all areas that needed to be address were now on the new form.


raw_content: A caregiver left 4 children in a van without any supervision on 2 occasions.

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: This standard was evaluated and found to be in compliance.


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

raw_content: Two children 13 and 10 years old were left unsupervised by a caregiver in a vehicle and engaged in inappropriate sexual behavior.


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

raw_content: Two of the children's service plan required "constant" supervision; this was not followed.


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

raw_content: There were two employees that had expired training in Normalcy.  The last date the  training was taken was 3/6/22.

Category: Training and Professional Development

Correction Narrative: An email was received by the Administrator indicating that the training has been completed with the staff. The certificates were requested.  A copy of the certificates was received, and the staff did complete the training on 5/23/23.  Also, a copy of the check list that was created to document the training dates.


summary: 748.2203(c)(1) - Medication Error-Document the time & date of the error

raw_content: Medications skipped or not filled in a timely manner were not documented as required for all prescribed medications.

Correction Narrative: An email was received from the Administrator indicating that a training with the staff was completed on ensuring all medication is filled out correctly. A in person follow up will be conducted the week of 4/10/23. An unannounced inspection was completed with the operation and medication was reviewed. There were no concerns.


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

raw_content: Staff did not administer medications to children in care as prescribed by the physician.


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: Incident reports provide insufficient information on interventions before and after an incident and it does not state who spoke to the child/children in care.

Correction Narrative: An email was received from the Administrator indicating that the operation has two different forms, and the incorrect form was used.  A training was completed with the staff and a new form was created to have all required information.  A copy of the form was received.


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

raw_content: There was mold along a wall in a child's sleeping area.  In addition, there was a broken toilet lid in the children's bathroom.

Category: Physical Site

Correction Narrative: This standard has been evaluated and found to be in compliance.


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

raw_content: The count on a medication log that was reviewed did not match the count of medications in the bottle. There were 30 pills in the bottle and there were 27 pills documented on the medication log.

Correction Narrative: An email was received from the Administrator stating that the medication forms have been updated to a newer version.  The staff were trained on the new form on 6/12/21.  Protocol for medication routine was assigned to a specific staff to include: ordering, picking up from pharmacy, counting medication in bottle when picked up from pharmacy, reconciling pills in bottle to number of medication log on a weekly basis and monitoring for accurate completion of logs.  An inspection is scheduled for 8/25/21.


facility_name: The Jim H. Green Kidz Harbor, Inc. dba Kidz Harbor Home

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: During the inspection, children files were observed to be missing orientation for this operation.

Category: Admission, Service Planning, Discharge

Standard Risk Level: Medium Low

Correction Narrative: The operation provided signed copies of the orientation and House Rules. The copies were signed by the resident and staff. The signed copy has been added to the child's file.


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: During the inspection, staff files reviewed were observed to be missing the 2912 affidavit.

Category: Reports and Record Keeping

Correction Narrative: The operation provided a signed copy of the 2912 Form for the staff file reviewed.


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

raw_content: It was observed during the inspection that fire inspection expired on 10/06/2024.

Category: Safety and Emergency Practices

Correction Narrative: Fire inspection was completed and was passed as of 11/27/2024.


summary: 748.867(b)(3) - A caregiver/employee is exempt from completing 2 hrs of normalcy training if the caregiver/employee can document that the training was received.

Correction Narrative:
748.867(b)(3) A caregiver/employee is exempt from completing 2 hrs of normalcy training if the caregiver/employee can document that the training was received. (Weight: Medium Low)
	Staff file reviewed did not have an updated copy of the normalcy training.	The normalcy for Angelina was in her file. It was just overlooked and I sent it immediately at 3:21 pm to the license representative. I'm also attaching a copy for corrective action.


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

raw_content: One of the four child's file reviewed was missing the required signature for child's rights on file.

Category: Children's Rights

Correction Narrative: Case Manger to ensure that required  documents are received from case workers in a timely manner and filed in the children files. There was an email requesting the child' right signed paperwork from case worker but was never followed up to ensure KH received it. Attached is the signed document (child's right)


summary: 748.930(b)(4) - Annual Training- Caregivers must have 2 hours transportation safety training if caring for children younger than 9 yrs old.

raw_content: Five staff members file reviewed; operation did not have current transportation safety training available during inspection.

Correction Narrative:
Administrator to ensure that training is filed into the personnel files within 24 hours after training is completed.

Attached are the training and certificates for the 5 staff members. (document library)


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: Two of the service plans reviewed were not signed by any of the participating parties.

Standard Risk Level: Low

Correction Narrative: Follow-up was conducted by inspection. Administrator provided a copy of the initial service plan with a signature of one Kidz Harbor staff. The operation will ensure all appropriate signatures are completed in future service plans.


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

raw_content: Staff are saying harsh, cruel demeaning things to children in care which include speaking of their future negatively.

Correction Narrative: Corrected


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

raw_content: In reviewing medication administration records. Three of four records reviewed show the staff who administered medication have their initials instead of their full names listed on the log.

Correction Narrative: A new form was completed with a space for printed names and will be used moving forward. The form was emailed and is located in client files.


facility_name: The Burke Foundation-Pathfinders RTC

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

raw_content: During the inspection it was determined the Sanitation Inspection was 10 days past annual due date.

Correction Narrative: On 3/31/26 the operation sent an email stating they have paid the required fee for the Health Inspection and are waiting for Hays County Health District to schedule a date of inspection. On 4/7/2026 the operation sent a copy of the health inspection (pass) by email. A physical site follow up was conducted on 4/15/2026.


summary: 748.936(1) - Annual Training-  Caregivers must have EBI w/in 6 months from the date they last received the training if operation provides treatment services

raw_content: It was observed staff did not meet EBI training requirements within 6 months from the date they last received training.

Correction Narrative:
On January 14, 2026, the operation reported they have audited all staff training records and scheduled immediate training for any staff out of compliance. A new program (Trainual) for training compliance is being implemented to ensure all staff training is up to standards.
On 1/20/2026 a physical site inspection was conducted. Two records for EBI training were sampled which includes the testing / written component. These caregiver records were compliant.


summary: 748.2551(d)(1) - EBI Implementation-Caregiver must make every effort to protect the child's privacy, including shielding the child from onlookers

raw_content: It was observed multiple children watched a child in care be restrained. One child walked by the restraint and taunted the child in the restraint.

Correction Narrative:
On January 14, 2026, the operation reported all staff will be retrained on the eye patrol protocol requiring removal or redirection of other children during any restraint. Staff have been trained on these procedures effective 01/16/2026.
On 1/20/2026 a physical site inspection was conducted. During this inspection a caregiver was selected at random for interview. The caregiver reported the operation trainer having a meeting / training in which they discussed additional efforts need to be made to follow operation policy. The caregiver reported the training also covered de-escalation and the need to find ways to avoid a restraint. During the training, it was impressed upon caregivers to be familiar with triggers, person specific de-escalation strategies and the goal is to avoid / reduce the use of restraints.


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

raw_content: It was observed a staff member used excessive force to initiate a restraint by grabbing a child in care's arm from behind and swinging them into a door.

Correction Narrative:
On January 14, 2026, the operation reported the staff member involved will receive additional coaching and training including 4 sessions of Equine Assisted Coaching (to be completed by 3/1/2026) and Handle with Care re-certification training 1/15/2026. EBI Instructors will continue to review all restraints to ensure compliance with minimal force standards. This Investigation was initiated from a self-report as a result of our own process of reviewing EBIs for minimum standard compliance.
On 1/20/2026 a physical site inspection was conducted. During this inspection a caregiver was selected at random for interview. The caregiver reported the operation having a meeting / training in which they discussed additional efforts need to be made to follow policy. The caregiver reported the training also covered de-escalation and the need to find ways to avoid a restraint. During the training, it was impressed upon caregivers to be familiar with triggers, and resident specific de-escalation strategies. The caregiver reported all staff having to take a class with the equine therapist. The caregiver explained the course conveyed that residents sense employee's mood. The caregiver explained the caregiver has to be in a good state of mind and calm when engaging with an escalated resident.


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

raw_content: It was observed a staff member restrained a child in care when they did not listen to staff directives to walk away from a sitting child.

Correction Narrative:
On January 14, 2026, the operation reported all staff will be retrained on the appropriate use of Emergency Behavior Intervention (EBI), emphasizing that EBI is never to be used as a means to gain compliance. Training will be completed by 1/16/2026, and ongoing monitoring will occur for each individual EBI review.
On 1/20/2026 a physical site inspection was conducted. During this inspection a caregiver was selected at random for interview. The caregiver reported the operation having a meeting / training in which they discussed additional efforts need to be made to follow policy. The caregiver reported the training also covered de-escalation and the need to find ways to avoid a restraint. During the training, it was impressed upon caregivers to be familiar with triggers, person specific de-escalation strategies and the goal is to avoid / reduce the use of restraints.  The caregiver reported all staff having to take a class with the equine therapist as well.


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 09/22/25 it was determined that:
(1) your operations administrator failed to ensure compliance with the current HM Plan;
and
(2) 12 months had elapsed since the effective date of the plan.
As you know, the heightened monitoring plan for your operation included a specific planned end date at the original 12-month mark by which your 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 plan, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your 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 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 09/22/25.  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 749.635(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is 03/23/2026.


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

raw_content: Review of the SIR showed that the runaway incident occurred at 12:59 AM on 8/29/2025 and the caseworkers were not informed until 8:00 AM on 8/30/2025 which is outside of the 6 hour requirment.

Correction Narrative: On 10/28/2025 a follow-up for this correction was conducted during a HM inspection. The Quality Assurance director created a process in the P2P system that is accessible through cell phone app Microsoft and on the operations computer. The system in place is a program with fields to be complete by staff. The residents case worker with DFPS automatically pre-fills the email field. The program also provides information on time frame reporting requirements and who should be notified. This system was viewed on the computer during the inspection.


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

raw_content: A child concealed and saved four pills over the course of two weeks during medication administration. The child intentionally ingested all four at a later time and required medical attention.

Correction Narrative: On 10/10/2025 the department received a certificate of medication retraining. The training was conducted by the operation nurse to all caregivers permitted to administer medication.  A summary of the instruction is documented. The certificate has each caregiver's electronic signature who participated in the training. On 10/14/25 during a/an inspection, a caregiver was selected at random and interviewed. The caregiver confirmed the training did occur in addition to a test. The caregiver provided a verbal description of how caregivers were trained to administer, test for "cheeking" and document medication administration.


summary: 748.1013(a) - Child/caregiver ratio-A caregiver must be awake when caring for a child needing constant supervision

raw_content: A child in care reported seeing a caregiver sleeping while on duty. The child called out to the caregiver twice for permission to use the restroom with no response. Caregiver reported to doze off on multiple occasions.

Correction Narrative: On 5/12/2025 the department received a corrective action plan. Going forward the operation will have a total of three-night shift assigned to work. They will rotate every other hour to ensure they remain alert. Management will emphasize the importance of maintaining a healthy sleep schedule and maintaining a work/life balance during CPI training and during the refresher trainings we do. Management will also be speaking with the caregiver who works this night shift. On 5/12/2025 a physical site inspection occurred for this correction


raw_content: Three children in care reported seeing a caregiver sleeping during the night shift with no other caregivers present. One caregiver reported waking this caregiver up upon starting a morning shift.

Standard Number / Description: 748.1013(a) - Child/caregiver ratio-A caregiver must be awake when caring for a child needing constant supervision

Correction Narrative: On 5/9/2025 the department received a corrective action plan. Going forward the operation will have a total of three-night shift assigned to work. They will rotate every other hour to ensure they remain alert. Management will emphasize the importance of maintaining a healthy sleep schedule and maintaining a work/life balance during CPI training and during the refresher trainings we do. On 5/12/2025 a physical site follow-up occurred for this correction.


raw_content:
During a review conducted on 03/20/2025 it was determined that:
(1) your operations administrator failed to ensure compliance with the current HM Plan;
and
(2) 12 months had elapsed since the effective date of the plan.
As you know, the heightened monitoring plan for your operation included a specific planned end date at the original 12-month mark by which your 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 plan, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your 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:
Your operation received a high-weighted citation in a pattern/trend category on 03/14/2025. Specifically, the operation was cited for 748.507(1).  It was found that a former direct care staff allowed children in care to participate in tug-o-war/wrestling with each other and this staff person was involved in the wrestling as well. It was reported that this staff also allowed the children to take off their shirts while working out in the weight room due to a lack in adequate A/C being available.
- 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 03/21/2025.  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 749.635(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is 09/21/2025.


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

raw_content: After a resident asked for additional food in the cafeteria, an employee tossed a food tray in the direction a resident striking their rib and landing on the floor.

Correction Narrative:
On 4/14/2025 the operation sent records of training for the employee for the dates 2/28/2025 and 3/5/2025. Title of the training is listed as Incident Specific_ Prudent Judgement, that addressed the use of humor without physical action on 2/28/2025.The training was facilitated by the Treatment Director and a credit of 1hr was earned.
Record of Equine Therapy session was provided in which the employee participated in a session on 3/5/2025. The Equine Therapist facilitated the session in which the P.A.U.S.E. method was explored with the employee. This method targets leadership and prevention personal space violations.


summary: 748.1661(b) - Tobacco Products-Adult may not smoke tobacco products, e-cigarettes, or vaporizers in children's living areas/inside any building on premises w/ kids

raw_content: An employee was seen using a vaporizer inside the residents living area at the front desk.

Correction Narrative:
On 2/3/2025 both employees were terminated from employment at the facility.
Written corrections were received on 3/12/2025.
All staff were required to read the Alcohol and Tabacco and Drug Policy in the employee handbook and sign stating they understood. The correction addresses use and storage of tobacco products at the facility. All signatures were electronically signed with a date and time stamp.
Employee Handbook  Alcohol, Tabacco and Drug Policy - #j
Use of tobacco products in any vehicles or property owned by or under the control of the Burke Center for Youth is prohibited. Employees, if transporting residents in their private vehicle, may not use tobacco products in any form while in the presence of a child. Tobacco use of any kind by employees is prohibited at Pathfinders Ranch property.

Nicotine inhalers are permitted only outside of all
Burke Center buildings, and never in front of children.

Physical Site follow up was conducted on 3/18/2025


raw_content: Two employees were observed inappropriately touching each other at the front desk of the operation and entering a supply closet together for approx. 5 mins.

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

Correction Narrative:
On 2/3/2025 both employees were terminated from employment at the facility.
Written corrections were received on 3/12/2025.
All employees were required to read the Employment #11 section of the employee handbook. All signatures were electronically signed with a date and time stamp.

Should a relationship change or develop between two existing employees, or should a relationship be brought to the attention of a supervisor, consultation must take place with the individuals concerned and arrangements put in place so as to comply with this policy. Management should consider any potential interpersonal or operating problems and minimize these by ensuring that the people concerned do not work on the same shift/in the same office when possible and ensuring that other employees in the workplace are confident that they can raise issues where they have concerns that the relationship in question is having
a detrimental effect on the working environment, or on operational issues. Where there are serious concerns about the effect a relationship is having, either on one or both of the employees' performance, on others within the team, or especially with our children in care, consultation will take place with the staff involved which may result in one or both of the staff members being redeployed within the organization.
Program Director states "Keep your personal relationships out of the workplace. There should be no displays of affection or personal conversations at any time while on shift. Failure to follow
this policy can result in corrective action."
Physical Site follow up was conducted on 3/18/2025


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

raw_content: A caregiver was observed via camera, outside the dorm in a car, leaving residents unsupervised for approximately 10 min.

Correction Narrative:
On 2/3/2025 both employees were terminated from employment at the facility.
Written corrections were received on 3/12/2025.
All employees were required to read the Program Policy for Supervision. All signatures were electronically signed with a date and time stamp.

During the children's waking hours, the minimum required ratio is 1:5 during waking hours, 1:15 during sleeping hours. The Program Director noted in this correction "Children will never be left alone
or unsupervised. In the event a caregiver needs to
step out of the area, they should notify another staff to make sure ratio and supervision is
covered. Never just leave without notifying a supervisor or finding coverage for your kids."

Physical Site follow up was conducted on 3/18/2025


raw_content:
During a review conducted on 09/19/2024 it was determined that:
(1) your operations administrator failed to ensure compliance with the current HM Plan;
and
(2) 12 months had elapsed since the effective date of the plan.
As you know, the heightened monitoring plan for your operation included a specific planned end date at the original 12-month mark by which your 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 plan, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your 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:
Your operation received a high-weighted citation in a pattern/trend category on 08/30/24. Specifically, the operation was cited for 748.2605(a)(5).  While reviewing video footage a staff was observed twisting a child's arm behind their back during an improper restraint.
- 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 09/19/2029.  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 749.635(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is 03/13/2025.


raw_content: During the investigation, a caregiver admitted to falling asleep on multiple occasions on an overnight shift.

Correction Narrative: On 10/10/2024 the operation sent a corrective action. On 9/13/2024 the Operation's Coordinator met with all night staff on and discussed the requirements that staff must remain awake during the night hours. The operation also added an additional staff to work nights going forward. This brings the total to three staff at night. The extra staff will float between the two sides of the unit. On 10/15/2024 a physical site follow-up occurred during HM inspection 4024798. On 10/18/2024 the department obtained a record of signatures by the night staff who attended the meeting with the Operation's Coordinator on 9/13/2024.


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

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

Correction Narrative: On 9/3/2024 HM received an email from the operation. The operation acknowledged the situation was not handled well and this is why a safety plan was implemented on the same day a report was made. The trainings on de-escalation and TBRI are aligned with child's rights and using praise/positive reinforcement, focusing on the rule to learn and the reason to the rule, and focusing on solutions that are respectful, reasonable, and related to the problem behavior. This training occurred on 9/3/2024. The staff member involved is no longer with the facility and a letter of discharge was received. A physical site follow-up inspection occurred on 9/17/2024. See inspection 4020094.


summary: 748.2605(a)(5) - Personal Restraints Prohibited-Restraints that twist or place the child's limb(s) behind the child's back

raw_content: While reviewing video footage a staff was observed twisting a child's arm behind their back during an improper restraint.

Correction Narrative: On 9/3/2024 HM received an email from the operation. The staff member involved is no longer with the facility. The operation has trained all staff on de-escalation techniques and on TBRI on 9/3. The operation is now operating on the CPI 3.0 method with an emphasis on de-escalation. Certificates of training were received by the operation. A physical site follow-up inspection occurred on 9/17/2024. See inspection 4020094.


summary: 748.2461(b)(6) - Short Personal Restraint-Caregiver may not use restraint that twists or places the child's limb(s) behind the child's back

raw_content: Through interviews and video footage, it was determined that a staff twisted a child's arm behind their back during a hold.

Correction Narrative: The operation began a corrective action plan while the investigation was ongoing. The caregiver involved was placed on a safety plan by the operation and resigned as a result of the safety plan. The operation conducted EBI training on August 6, 2024, starting at 9AM. The training covered the use of EBI only in emergency or crisis situations. An additional training is scheduled for September 3rd. This training will be conducted by the Equine Specialist and will further focus on de-escalation. The operation is transitioning from CPI 2.0 to CPI 3.0 which focuses more on de-escalation. On 8/20/2024 a physical site follow-up occurred during a Heightened Monitoring inspection. The Administrator was currently in EBI training to become a certified CPI trainer in addition to the current two trainers employed at the operation.


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

raw_content: Through interviews and video footage, it was determined that a staff performed an inappropriate and unwarranted intervention on a child in care.

Correction Narrative: The operation began a corrective action plan while the investigation was ongoing. The operation conducted an EBI training on August 6, 2024 starting at 9AM. The training covered using EBI only in emergency or crisis situations. An additional training is scheduled for September 3rd. This training will be conducted by the Equine Specialist and will further focus on de-escalation.


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

raw_content: Through interviews and video footage, it was determined that staff did not attempt to de-escalate a child before using emergency behavior intervention.


raw_content: It was observed through video footage, that a staff was pushing and pulling on a child in care when escorting the child.

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


summary: 748.1351 - Initial Service Plan-Implement & follow plan as soon as all team members have reviewed/signed it, but no later than 15 days after date of meeting

raw_content: In the ISP under the 'services to address high risk behavior' it states staff are to use the least restrictive method unless the resident is walking past the soccer field. Staff did not adhere to these instructions when restraining the child inside the operation.

Correction Narrative:
The operation sent a copy of the residents De-escalation preferences form. This was utilized on the resident in this case and is utilized for each new admission. The operation also sent a copy of the 3 Step De-escalation / 5 step conflict resolution process use3 Step De-escalation:
1.Ignore The Words
2.Guess At The Emotions
3. Reflect The Emotions with a Simple "you" Statement.
5 Step Conflict Resolution:
1.Affirm the relationship
2. Seek to understand
3. Respectfully share your point of view
4. Own responsibility
5 Seek agreement


raw_content: A child in care was restrained at the door of the operation and escorted to a couch where the restrain resumed to prevent the resident from going outside.

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

Correction Narrative:
The operation sent an email showing the operation utilizes a de-escalation preferences form. The operation then takes this information and loads it into their database which is a peer to peer set up. Staff are able to access this information any time through the application. Additionally, the operations Treatment Director will load everything about the admission in the Placement Description section. This provides staff access to child's last psychological and CANS evaluation. All are sent this in advance before the child arrives.

For new staff who come in not knowing the resident, they are given time (during training) to go over the peer to peer and familiarize themselves with the application and instructed to review each child's information.

5 screenshot images were sent of the P2P program staff have access too.


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

raw_content: The preliminary service plan did not indicate the child has autism spectrum disorder.

Correction Narrative: On 7/12/2024 the department received an email from the operation. The operation will include information from a common app and psychological if one is has been provided prior to admission.


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 operation did not document a restraint report for the incident.

Correction Narrative:
On 7/17/2024 the department received an email with four attachments. Each attachment is for each Staff directly and indirectly involved in the investigation. The Administrator of the operation held a discussion with each Staff. The Administrator and Staff involved, signed, and dated the record of discussion. One of the three Staff involved included the CEO and Operations Coordinator being involved in which a signature and date is documented as well.
Discussed with Staff
The difference between an EBI restraint and a short personal hold. When an EBI report would be needed. What constitutes a short personal hold and when, for example, a child goes to the ground it would then change to an EBI even if it was under a minute. The definition of excessive use of force and when/how to write EBI reports for each individual incident. If a Staff is ever unsure whether a situation falls into a short personal hold or EBI, they will contact the Administrator for guidance / clarification. The investigation and findings were discussed with the staff involved in this case.
The operation will conduct and all staff training on August 6th at 9AM. The all-staff training will discuss EBI and restraints. All staff will be required to sign a log to show attendance of this training. Additionally, the operation will include what was discussed and who facilitated the training. The operation has been notified a site follow up for the all-staff training will occur the week of training to obtain this record. The Administrator has confirmed they understand and will provide this. This follow up information will be noted in the HM inspection Chronology for the week of August 5th -9th week.


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

raw_content: A child in care was held in a restraint for an excessive amount of time.

Correction Narrative:
On 7/17/2024 the department received an email with four attachments. Each attachment is for each Staff directly and indirectly involved in the investigation. The Administrator of the operation held a discussion with each Staff. The Administrator and Staff involved, signed, and dated the record of discussion. One of the three Staff involved included the CEO and Operations Coordinator being involved in which a signature and date is documented as well.
Discussed with Staff
The difference between an EBI restraint and a short personal hold. When an EBI report would be needed. What constitutes a short personal hold and when, for example, a child goes to the ground it would then change to an EBI even if it was under a minute. The definition of excessive use of force and when/how to write EBI reports for each individual incident. If a Staff is ever unsure whether a situation falls into a short personal hold or EBI, they will contact the Administrator for guidance / clarification. The investigation and findings were discussed with the staff involved in this case.
The operation will conduct and all staff training on August 6th at 9AM. The all-staff training will discuss EBI and restraints. All staff will be required to sign a log to show attendance of this training. Additionally, the operation will include what was discussed and who facilitated the training. The operation has been notified a site follow up for the all-staff training will occur the week of training to obtain this record. The Administrator has confirmed they understand and will provide this. This follow up information will be noted in the HM inspection Chronology for the week of August 5th -9th week.
8/8/2024 This is a physical site follow up for Investigation 3089872. A power point of the training was received and a list of staff who attended. Additionally, a staff interview occurred inquiring about the training in which the staff reported management discussing EBI, run away protocols and the nurse discussing the importance of keeping residents hydrated and how to contact her.
On 8/20/2024 a physical site follow-up occurred. This is a physical site follow up for Investigation 3089872. A power point of the training was received and a list of staff who attended. Additionally, a staff interview occurred inquiring about the training.


summary: 748.2801(1) - EBI Time Limits-Maximum length of time for short personal restraint is one minute

raw_content: A child in care was restrained for over 10 minutes.


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 03/18/2024 it was determined that:
(1)	your operations administrator failed to ensure compliance with the current HM Plan; and
(2)	12 months had elapsed since the effective date of the plan.
As you know, the heightened monitoring plan for your operation included a specific planned end date at the original 12-month mark by which your 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 plan, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your 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:
Your operation received a high-weighted citation in a pattern/trend category on 01/08/24. Specifically, the operation was cited for 748.685(a)(4). It was reported that a staff is on their phone or computer a lot of the time looking at social media (such as Instagram, Tik Tok, and/or Facebook) or YouTube while working and while supervising children in care.
- 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.

Finding: 748.535(2)  The licensed administrator must ensure the operation complies with current heightened monitoring plans.

Correction Narrative: An HM extension was approved effective 03/18/2023.  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 749.635(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is 09/18/2024.


summary: 748.705(b)(9) - Reasonable & prudent parent standard-must consider the supervision instructions in the child's service plan

raw_content: Two caregivers failed to provide a child a high level of supervision which was required by the instructions on their service plans.

Correction Narrative: The operation sent an email to this rep on 3/26/24 reported the details of the incident were discussed with each caregiver by both the Pathfinders Program Director and Pathfinders Treatment Director independently. The caregivers were reminded of the general supervision requirements for all children in their program and that staff are expected to periodically review the specific service plan instructions on each individual child in their program. It was reported that staff have easy access to individual treatment plans through their private Teams App on their phones and at any time needed, staff can review this information prior to working with any child as well as when the plans are updated, that it is a simple 3 click process.


summary: 745.4151(c)(7)(A) - Appeal drug test results-Applicant or employee may, at own expense explain or offer documentation for the positive drug test

raw_content: An employee at the operation tested positive for THC and did not provide the required documention to substantiate the positive result.

Correction Narrative: The operation emailed me a negative drug screen for the staff.


summary: 748.3105(b) - Fire Inspection-Must comply with local code & all corrections, restrictions, or conditions specified by inspector in fire inspection report

raw_content: The operation had a failed fire inspection in July 2023 and a follow up inspection in November 2023 and were recited for two of the same violations.

Correction Narrative:
The operation emailed a passed fire inspection that is uploaded to the document library and a follow up inspection was conducted at the operation.

12/4/23 - An extension is being granted until 12/09 due to the operation sent me an email confirmation from the fire marshall stating that he would be returning for an inspection on 12/08.


raw_content: It was reported that a staff is on their phone or computer a lot of the time looking at social media (such as Instagram, Tik Tok, and/or Facebook) or YouTube while working and while supervising children in care.

Correction Narrative: The operation reported that management conducted a discussion with staff regarding supervision of the children and the importance of not being on their phone when supervising the children. The operation also reported that the staff on their phone is no longer employed. An email was provided by the treatment director stating that they spoke to the Coordinators regarding child/caregiver interactions and supervision and the Coordinators spoke to their staff in each dorm.


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

raw_content: It was reported that for the incident a staff argued back and forth with a child in care, yelled and said shut up to the same child and other children in care and did not de-escalate the situation properly. Additionally, this same staff was reported to have made threats of consequences to children in care for asking a question and making inappropriate comments about children in care sitting next to each other.

Correction Narrative: The operation reported that management spoke to staff regarding their interactions with children and to be mindful of the things they say to the children and in front of the children. The operation also reported that the staff that did this is no longer employed at the operation.


summary: 748.303(e)(9)(A) - Serious Incident- Report to CCL w/in 24hrs of becoming aware of an allegation of an employee using a prohibited or inappropriate EBI technique.

raw_content: The operation staff conducts a monthly interview with the children in care and did not report when a child alleged that a staff inappropriately restrained him.

Correction Narrative: A discussion between the administrator and staff was conducted to ensure that the staff knows if they receive a report of abuse or neglect that it must be reported and that the staff know how to report it via the hotline.


raw_content:
During a review conducted on 09/15/2023 it was determined that:
(1)	your operations administrator failed to ensure compliance with the current HM Plan; and
(2)	12 months had elapsed since the effective date of the plan.
As you know, the heightened monitoring plan for your operation included a specific planned end date at the original 12-month mark by which your 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 plan, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your 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:
Your operation received a high-weighted citation in a pattern/trend category on 09/01/2023. Specifically, the operation was cited for 748.1101(b)(4)(A) It was found that a staff person treated a child in care unfairly by giving unnecessary discipline and/or excessive consequences to this child.

 - 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.

Finding: 748.535(2)  The licensed administrator must ensure the operation complies with current heightened monitoring plans.

Correction Narrative: An HM extension was approved effective 09/16/2023.  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 749.635(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is 03/16/2024.


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

raw_content: A staff member did not use prudent judgment when he told a child, "You cannot join the military if you pee the bed."

Correction Narrative: The treatment director had a discussion with staff and told him to be mindful about how he speaks wiith children.


summary: 748.1661(b) - Tobacco Products-Adult may not smoke tobacco products, e-cigarettes, or vaporizers in children's living areas/inside any building on premises w/ kids

raw_content:
A staff member admitted to vaping in the buildings on campus. The staff member explained they step into a room where the children are not currently present then will vape. Staff stated this is allowed as long as it is not in sight of the children.

The tobacco policy does not dictate that staff may not vape in children's living areas/inside any building on premises with children, only that is it is not to be done in front of children.

Correction Narrative: The tobacco use policy for the operation was updated to meet minimum standards and sent to the staff to sign off on acknowledging that they received and reviewed the policy. The policy states that tobacco products will not be used in any facility used by the children even if children are not present at the time.


raw_content: After reviewing video footage and from interviews, it is determined that a child was placed in a restraint for a non-emergency situation.

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

Correction Narrative: The Treatment Director stated that staff has been given a verbal directive to not implement EBI's. The staff also participated in the Equine therapy that the children engage in to get a better understanding of the children and hopefully be able to read and engage with them more effectively.


raw_content: When reviewing video footage, one staff is seen pushing down on the back of Noah and pushing him towards the ground.

Correction Narrative: The Treatment Director stated that staff has been given a verbal directive to not implement EBI's. The staff also participated in the Equine therapy that the children engage in to get a better understanding of the horses and children and hopefully be able to read and communicate with them more effectively. The operation is also going to implement a new EBI curriculum to give the staff more options to utilize when a child is escalated.


raw_content: A restraint implemented on 5/16 had not been documented within the required 24 hour period.

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

Correction Narrative: Administrator had a discussion with staff regarding the documentation of the EBI. This particular staff was under the impression that the Operation Coordinator had documented it since she was also involved.


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

raw_content: A restraint given on 5/16 did not have a review by a supervisor documented within the required 72 hours of the incident occurring.

Correction Narrative: The administrator was not aware there was an EBI to review; therefore, it was not done. He spoke with staff regarding the incident and determined it was a miscommunication.


raw_content: It was found that one staff used a vape pen and vaped on multiple occasions in front of and/or near children in care. The operation was cited for this standard in July 2022 as well.

Standard Number / Description: 748.1661(b) - Tobacco Products-Adult may not smoke tobacco products, e-cigarettes, or vaporizers in children's living areas/inside any building on premises w/ kids

Correction Narrative:
On 6/28/23, HM Inspector, Sonia Arndt conducted a physical follow up at the operation. The incident was discussed with management who stated that they spoke to the employee regarding the use of tobacco products and in the future, staff will utilize a tobacco patch or nicotine gum and not bring a vape or tobacco products on the premises or use them in front of the children or around the children.

On 6/23/23, through email the operation reported that a discussion was held with the staff in question, and this staff has been informed that they are not to use a Vaporizer while on campus.  This staff works the weekend shift 3 days in a row and spends the night on campus to avoid the long ride back home between shifts. The Administrator has provided this staff with Patches to help alleviate the situation. All other staff have been informed of the expectation that they do not smoke tobacco products, use e-cigarettes, or vaporizers while on campus. The agency reported, as for the citation for this standard in July 2022, that staff no longer works for the operation.


raw_content: A child was observed outside doing jumping jacks when he was restrained by staff in a non-emergency situation.

Correction Narrative: Treatment director has conducted at least three trainings and discussed child rights and EBI. The staff have all been involved in Equine therapy to learn how to read the horses in hopes that the training will assist with de-escalation leadding to fewer restraints.


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

raw_content: In an investigation conducted by DFPS, two staff were found reason to believe for physical abuse of a child.


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

raw_content: The caregiver was observed grabbing the child's shirt and belt loop, wrestling with him on the ground, and forcing him to sit in a chair, which are not approved methods of EBI.


summary: 748.2553(2)(C) - EBI Release-Child released from personal restraint as soon as child is not a danger to self or others

raw_content: Three staff were observed on video holding a child on the ground in a restraint for at least four minutes after he was no longer a danger to himself or others and had expressed that his foot was injured.

Correction Narrative: The EBI training is no longer a general training after each EBI the training is specific to that particular EBI for that employee. They watch the video and discuss de-escalation amd what could have been done differrently.


raw_content: Staff was observed via the EBI video, using excessive force when he lifted the child off of the ground during a restraint, causing the child's feet to drag; consequently, causing both child and staff to fall to the ground and  injuring the child's foot.

Correction Narrative: The EBI training is no longer a general training after each EBI the training is specific to that particular EBI for that employee. They watch the video and discuss de-escalation and what could have been done differrently.


summary: 748.2461(b)(6) - Short Personal Restraint-Caregiver may not use restraint that twists or places the child's limb(s) behind the child's back

raw_content: Two caregivers were observed pushing down on the child's back, while both caregivers each held one arm and were pulling back and up on the child's arms until both arms were extended and behind his back.


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

raw_content: A staff was observed on video restraining a child in a non-emergency situation.

Correction Narrative: Staff will be retrained on de-escalation and different ways to de-escalate situations. The video will be shown to the staff again and go over step by step ways that the restraint could have been avoided.


raw_content: Staff was observed holding a child's arms behind his back during a restraint.

Standard Number / Description: 748.2461(b)(6) - Short Personal Restraint-Caregiver may not use restraint that twists or places the child's limb(s) behind the child's back

Correction Narrative: Staff was retrained regarding HWC holds by the trainer andl practiced the hold several times plus the post EBI discussion went over the video and Administrator discussed how to correctly complete the holds staff was originally attempting to impleiment.


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: I observed a total of 6 fire extinguishers in the boys' dorms.  All 6 fire extinguishers were inspected in February 2022.

Correction Narrative: The fire extinguishers in the boys dorms display a tag with the month of March and the Year 2023.  All of the fire extinguishes were serviced and compliant..


summary: 748.2307(13) - Other Prohibited Punishments-denying basic child rights as discipline or punishment

raw_content: Based on information obtained, it was determined that a child was denied basic rights as a discipline when the child did not comply to staff directives. (The child was not allowed to go into the cafeteria and eat until he quit making noises)

Correction Narrative: The administrator held an all staff meeting where training regarding child rights was given. An agenda to the meeting was provided as proof of compliance.


raw_content:
During a review conducted on 03/13/2023 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, including having an open investigation.

Correction Narrative: An HM extension was approved effective 9/10/2023.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your CPA/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 14, 2023.


summary: HRC42.04412(a) - Interference with an investigation

raw_content: A listening device was secretly placed in a room where RC staff were conducting interviews. This was noticed by RC staff and the device was turned off. The person who planted this device admitted to doing this at the request of the administrator.

Correction Narrative: There was a discussion with the administrator regarding how his actions were interfering with an investigation. The administrator consented to continue to allow Licensing to interview staff and children at a location of their choice. Several possible interview areas were assessed for safety during the walk through. The administrator agreed to adhere to Licensing's right to privacy when conducting interviews with children and staff.


raw_content: A staff was observed administering a restraint to a child in a non-emergency situation.

Correction Narrative: Regarding the staff implicated in the EBI which was the basis for the investigation:  Staff completed a 2 hour de-escalation training on 1/5/23. Annual training records for the staff were reviewed and contain 22 hours of EBI/De-escalation training as well as 9 hours of Trauma Informed Care training. A training schedule of the mandatory monthly trainings was obtained for November through March, and the current EBI training curriculum was reviewed and is in correlation with the rules in the minimum standards regarding EBI.


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 09/16/2022 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 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, including having an open investigation.

Correction Narrative: An HM extension was approved effective 9/10/2023.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your CPA/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 3/10/2023.


summary: 748.1583(b) - TB exam-Documentation of baseline test or chest xray results in person's record w/in 40 days of beginning to live, work, volunteer at facility

raw_content: Two out of two children's files reviewed did not contain results of a TB exam and both have been placed at the facility for over 40 days.

Correction Narrative:
The following email was received from the operation as their compliance plan:
Our process regarding intake documentation has been updated to include the use of scheduled automation to re-request any missing documentation from the state at placement. The automation will send follow-up requests at Placement, 30 days,  60 days, 90 days, and 180 days.

If the child's health passport contains TB test information for the child the case manager will add a snapshot of this to the E Case Record and mark that as sufficient documentation and will no longer request this from the state.
If proof of TB Test is not provided at intake, or there is no date in the child's health passport, Pathfinders will utilize a walk-in clinic to administer the test and our staff RN will read and verify results within the 48-72 hour window. The results of which will be placed in the Child's E Case Record and provided to their managing conservator.


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

raw_content: Based on information gathered through the course of the investigation it has been determined that children are not always being granted privacy when trying to make phone calls with their CPS worker or CASAs.

Correction Narrative:
Administrator sent the following plan.
This message was sent out over TEAMS tagging all staff, so they are notified to read it.  This is our corrective action for Investigation 2911447.
September 15, 2022  Investigation 2911447
We received a deficiency in:
§748.1101. What rights does a child in care have?
(b) The following categories include the child's rights that you must adhere to:
(3) Living a normal life, including:
(E) The right to privacy, including sending and receiving unopened mail, making and receiving phone calls, keeping a personal journal, and having visitors, unless the child's best interest, appropriate professionals, or court order necessitates restrictions [Medium];
All Staff please get with your Supervisors to discuss how to properly Monitor phone calls.  This standard has an exception included in it, unless the child's best interest, appropriate professionals, or court order necessitates restrictions.  Many of our kids have restrictions.  But, calls to Caseworkers and CASAs are never included in those restrictions.  Even if a CASA has a history of telling kids things like, Your Mothers Cancer is getting worse or Your mother will probably loose her rights in court in two weeks, and not telling us they have said this to the kid so we can offer him support or be prepared when the kid becomes exceptionally emotional and maybe violent, even then we are not allowed to listen in on the call.


raw_content: Based on interviews and documentation, it was determined that a child was restrained after throwing a canteen into open space.

Correction Narrative: On 9/6/2022 we held an all-staff training on EBI and they were reminded that restraints are only used in an emergency situation.


raw_content: It was determined during the course of this investigation that a staff member has used a vape in the childrens living quarters.

Correction Narrative: An email was received from the operation. This issue was addressed in person with the Program Director, supervisors, and staff. This was addressed with all staff during the monthly staffing meeting on 8.2.22.


raw_content:
During interviews with children and staff, as well as a review of emergency behavior intervention (EBI) documentation, it was determined staff have implemented EBI in situations which do not meet the definition of an emergency situation.
The information gathered indicates restraints have been used when a child walks out of supervision, or as a preventive measure when a child has been perceived to potentially escalate their peers behavior.

Correction Narrative:
The following response was provided by the operation's administrator:
An administrative review of this investigation is being requested. Emergency Behavior Intervention has not taken place on campus in years that wasn't based on an emergency situation. A child is never restrained for simply creating anxiety and fear in their peers. Usually, staff are compelled to attempt a short personal restraint or escort when a child becomes aggressive toward staff, or preventing a child with a history of high risk behavior from leaving supervision.

An inspection was conducted to follow up on this deficiency on 08/03/22, during which children and staff were interviewed. There was no information gathered during these interviews to indicate a child was restrained in a non-emergency situation since this deficiency was cited. The operation's administrator also reported having to review video footage of each restraint incident. Reviewing video is a measure which began on 05/05/22, at least.


summary: 748.2307(5) - Other Prohibited Punishments-maintaining an uncomfortable physical position

raw_content: During interviews with both children and staff, it was determined children occasionally have to hold the line for over 15 minutes. The manner in which holding the line was characterized suggests this is a disciplinary measure, to include the following characteristics: a child having to stand straight up, facing forward, with their hands behind their backs and toes on the line, all while remaining silent.

Correction Narrative:
An email was received from the operation. This issue was addressed in person with the Program Director, supervisors, and staff. This was addressed with all staff during the monthly staffing meeting on 8.2.22.
Holding the line for extended periods of time was assessed by the Program Director and the operation denies it taking place. However, it has been addressed with staff.


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

raw_content: Seven children interviewed, along with three staff, explained staff have used profane language around children in care.

Correction Narrative: An email was received from the operation. This issue was addressed in person with the Program Director, supervisors, and staff. This was addressed with all staff during the monthly staffing meeting on 8.2.22. Staff were reminded regulatory standards requires a higher standard than normal modern language. Supervisors were advised they are responsible for correcting the language of staff.


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

raw_content: Six children interviewed during the course of this investigation, along with two staff, confirmed that staff have yelled at children in care.

Correction Narrative: An email was received from the operation. This issue was addressed in person with the Program Director, supervisors, and staff. This was addressed with all staff during the monthly staffing meeting on 8.2.22. Supervisors were advised they are responsible for their staff making appropriate use of their voice.


raw_content: 6 children interviewed explained staff had used profane language around them, whether the staff was being negative or using the language in a "joking" manner.

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

Correction Narrative: An email was received from Jack Morrell. He let me know that an all staff training will be held on 2/1/2022 and will discuss the subject of discipline and using profane language. AR was requested.


raw_content: When observing video footage, it was observed that a child in care remained in a restraint after no longer being a threat to himself or those around him.

Standard Number / Description: 748.2553(2)(C) - EBI Release-Child released from personal restraint as soon as child is not a danger to self or others

Correction Narrative: The operation came into compliance on 12/14/2021 and was provided via email from Jack Morrell. A staff training was held and was a refresher for rules surrounding EBI. These rules were reiterated and included discussion and reminders on releasing a child as soon as they are no longer a danger to themselves or others. The operation also completed their corrective action plan. AR has been requested.


raw_content: Out of multiple interviews conducted with children and staff, it was confirmed that a caregiver openly calls the children in care "stupid" and humiliates children who have wet the bed by calling them "pee pee boy" or "bedwetter" in font of their peers by using shame as a discipline technique.

Standard Number / Description: 748.2307(8) - Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child

Correction Narrative: Administrator sent email stating they have trained the staff and put the Minimum Standard about not humiliating kids on TEAMS for all staff to be reminded of this requirement.


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

raw_content: There is sufficient evidence to show that a staff member is retaliating against a child in care they feel contacted Licensing about them. Both staff and children in care interviewed stated the staff member is retaliating against the child by calling the child allegations boy, licensing boy and making other comments openly to other children that penalize them for speaking with Licensing.

Correction Narrative: Administrator sent an email stating they were going to talk to the staff and all staff have been required to retake our training on children's rights within the next two weeks.


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

raw_content:
During the course of the investigation, according to video footage reviewed, on 11/17/21, a child in care initiated in what was characterized as "horseplay" and/or play fighting with one staff, in which the staff engaged in with the child resulting in a physical incident with the child, which included contact to the childs person. This behavior was inappropriate as the child's plan of service, completed on 08/01/21, notes a history of trauma, as well as a history of physical aggression and emotional dysregulation.

It was also reported that on the same day the aforementioned incident occurred, this staff engaged in "horseplay" with the resident by removing the child's bedsheet from their mattress as a joke and/or threw the childs mattress, bedding, and belongings about the childs room. It was reported that this staff "flipped" this child's room not as a consequence, but in a joking manner. The operation reported this staff's last day is 11/19/21.

Correction Narrative: The operation reported verbally by phone that the staff involved in the play fighting and horseplay will no longer be working for the oper. after today as today was their last day, unrelated to this incident, and they have already discussed with all staff that horseplay is not okay and that this is not appropriate behavior to engage in with children in care. The operation reported that they discussed this with all staff yesterday on 11/18/21 and today, 11/19/21.


raw_content: Through interviews it was determined that staff implemented an emergency behavior intervention when it was not an emergency situation. Staff were putting children in restraints for throwing objects such as rocks or sticks when others were not in imminent danger of being harmed and staff would put children in short personal restraints for not taking their hands out of their pockets.

Correction Narrative: A follow up inspection was conducted at the operation, during which children in care were interviewed. Emergency Behavior Intervention was assessed, and a walkthrough was conducted, with no concerns noted.


summary: 748.2307(15) - Other Prohibited Punishments-using or threatening to use emergency behavior intervention as discipline or punishment

raw_content: Based on interviews conducted and information obtained, it was determined that staff threatened to administer a restraint to a child in care. Subsequently, the child was placed in a restraint for failing to comply with directives.

Correction Narrative:
To meet compliance the operation offered two trainings related to EBI. Sept 8, 2021 Training  De-escalation and Target Behaviors - How De-escalation helps to calm a situation and avoid a restraint and November 2, 2021 Training - De-escalation, Shift, Safety, Structure, Supervision  Learning how to control our body language to keep a calm environment.

A follow up interview was conducted with victim child  who reported that staff has not threatened to use EBI as a punishment since this incident. Staff interviewed reported not witnessing any threats to use EBI as a punishment.


raw_content: During the course of this investigation, it was determined that staff administered a restraint to a child in care in a nonemergency situation when the child's behavior was refusing to lay down and refusing to go to sleep.

Correction Narrative:
To meet compliance the operation offered two trainings related to EBI. Sept 8, 2021 Training  De-escalation and Target Behaviors - How De-escalation helps to calm a situation and avoid a restraint and November 2, 2021 Training - De-escalation, Shift, Safety, Structure, Supervision  Learning how to control our body language to keep a calm environment.

A follow up interview was conducted with victim child  who reported that staff has not used EBI when it was not an emergency situation since this incident. Staff interviewed reported not witnessing EBI being used when it was not an emergency situation.


facility_name: Promise Rose Residential Care Home, Inc.

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

raw_content: All children's records reviewed did not have a initial service plan meeting notice in the file.

Correction Narrative:
The operation sent the following corrective action:

Promise rose will continue to follow the Childcare Licensing Minimum standards for General Residential Operations regarding children's records. Case manager, Nakiya Brite will continue to file the initial service plan notice in the binders. Instead of placing the notices in the case management portion of the binder, she will include it with the service plan.


raw_content: Three Children in care and 1 collateral adult observed a staff member to be horseplaying with a child in care.

Correction Narrative: Promise Rose will ensure that the staff members attend training. The signing sheet will be forwarded to the RCCL Inspector by June 13, 2025. Sing in sheet was provided with staff that attended the training. Who provided the training and the instructor that provided the training.


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

raw_content:
One service plan was observed to be missing documentation, leaving a section of the plan blank. Documentation on a Texas Health Steps Dental
Exam was observed with four blank pages omitting pertinent information.

Correction Narrative: The Case Manager will audit all forms after returning from the children's appointments. CM will file the forms in the appropriate sections of the binder.


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

raw_content: A staff member hired on 01/08/2025 did not complete the Psychotropic Medication Training until three months later on 04/20/2025.

Correction Narrative: Executive Director will audit employee binders bi-weekly and ensure that trainings are up to date and filed properly.


summary: 748.935(a)(2) - Annual Training Timeline-Each person must complete the required annual training during each subsequent 12-month period

raw_content: The operation's Administrator was observed to have completed two annual trainings (Trauma Informed Care and Psychotropic Medication) on 01/04/24 and not again until 01/09/25; 5 days late.


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

raw_content: Three serious incidents observed were found to not have been reported to Licensing.

Correction Narrative: Director, Nikia Johnson, emailed the following corrective action: Promise Rose will continue to follow the Child Care licensing Minimum Standards for GRO's. Promise Rose will ensure that all staff are properly trained in what and when to report serious incidents reports. A refresher course will be conducted on October 24, 2024, for all employees.


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

raw_content: A copy of an employee's current First Aid Training Certificate could not be located.

Correction Narrative: Director, Nikia Johnson, emailed the following corrective action: Promise Rose will ensure that all CPR cards are filed in the employee binders.


raw_content: Staff was responsible for supervising children doing an outing. Staff did not perform the assigned job duties and was sitting at the bar indulging in an alcoholic beverage.

Correction Narrative:
To remedy this incident and prevent future occurrences, LCCA, Executive Director, will provide mandatory supervision and safety training for all Promise Rose administrative staff, direct care staff, and volunteers.

LCCA and the Executive director will ensure compliance by Promise Rose administrative staff, direct care staff, and volunteers to document evidence of compliance in forms of sign-in sheets, certificates of completion, and learning materials by 3/30/2024.


summary: 748.2461(b)(6) - Short Personal Restraint-Caregiver may not use restraint that twists or places the child's limb(s) behind the child's back

raw_content: A child in care was inappropriately restrained at the operation.


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

raw_content: The report of a child's unauthorized absence from the facility was not submitted to Licensing until the following day.

Correction Narrative:
06/16/2023- Promise Rose Executive Director submitted a Corrective Action Plan via email to licensing staff.

According to the Action Plan of achieving the goal, Promise Rose will continue to follow the Child Care Licensing Minimum Standards for General Residential Operations.  Promise Rose will ensure all staff are properly trained and informed of how and when to contact the Texas Hotline, Licensing Representative, child's permanency team, and Contract Manager.

Promise Rose Program Director will conduct the training and submit the sign-in sheet by Wednesday, June 21, 2023.

Promise Rose will submit a sign-in sheet to licensing staff from all employees stating they are aware of the protocol on when to report a runaway.

07/03/2023- Promise Rose Executive Director submitted the PRRCH training with topic of Recognizing, Responding, and Reporting Serious Incidents (AWOL, Injuries, Abuse or Neglect) sign-in sheet for all staff. Promise Rose staff dated as well as signed the sign-in sheet indicating staff participated in the 2-Hour training on 06/19/2023.

Additionally, the sign-in sheet indicated training instructors were the Program Director as well as the LCCA/Treatment Director.


summary: 748.1339(b) - Initial Service Plan-For treatment services, service planning team must include two professionals

raw_content: Based on review of documents, it was found three out of four children's service plan did not reflect  two professionals' participation as well as two professionals' signatures.  The three children's service plans reviewed only contained a signature from one professsional.

Correction Narrative:
On 05/11/2023, Promise Rose Executive Director submitted a Corrective Action Plan to licensing staff indicating the operation will provide licensing staff a copy of the signature page for the children's next scheduled treatment plan on 06/03/2023.

Additionally, the Treatment Director will ensure all required personnel sign the signature page of the treatment plan and file all documents in the resident's binder.


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 four children's records reviewed did not have a documented TB Skin Test.

Category: Child Care

Correction Narrative:
On 05/11/2023, Promise Rose Executive Director submitted to licensing staff the child's vaccination record indicating the child was administered a TB Skin Test on 05/08/2023.

Additionally, the Executive Director submitted a Corrective Action Plan, indicating the Case Manager will ensure that all incoming residents are scheduled and administered a TB Skin Test Screening within the first 30 days of placement.  Results will be filed in the resident's binder.


summary: 748.125(d)(4)(C) - Suicide Screening- Must be administered every 30 days after admission for children 10 years of age or older in a residential treatment center.

raw_content: Based on an evaluation of documents, it was found four out of four active children's records did not contain documentation supporting a suicide screening was administed every 30 ays after admissionn.

Correction Narrative:
On 05/11/2023, Promise Rose Executive Director submitted to licensing staff a Corrective Action Plan indicating all residents were administered an ASQ Suicide Risk Screening Tool.  The results will be emailed to licensing staff.

Additionally, the Treatment Director will create a calendar reminder to ensure screenings are completed timely.


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

raw_content: Based on a walk-through of the operation's three cottages' kitchens, it was observed  the daily menu did not contain a daily food substitution for each meal.

Correction Narrative:
On 05/11/2023, Promise Rose Executive Director submitted to licensing staff a revised copy of the operation's menu including an alternative meal for breakfast, lunch as well as dinner.

Additionally, the Executive Director submitted a Corrective Action Plan indicating the Assistant Administrator will ensure that an updated copy of the menu is posted in all cottages.  If updates are necessary, the Assistant Administrator will also update all menus.


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

raw_content: Based on a review of documents, it was found three out of four children's initial service plans did not reflect at least one of the child's current caregivers participation as well as  cargivers signature.


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

raw_content: Based on a walk-through of the operation's three cottages, it was observed the evacuation plan did not contain a location inside each cottage where staff and children were to locate for shelter in place.

Correction Narrative:
On 05/11/2023, Promise Rose Executive Director submitted to licensing staff copies of the three cottages evacuation plan displaying the location inside each cottage where staff and children were to locate for shelter in place.

Additionally, the Executive Director submitted to licensing staff a Corrective Action Plan indicating the Director will ensure that the floor/evacuation plans are posted and visible in all areas of each cottage, including but not limited to bedrooms, living rooms, and media rooms.


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

raw_content: One of five staff interviewed failed to provide required constant supervision to a child in care as recommended in safety plan.

Correction Narrative: A copy of staff's training was submitted via email by Nakia Johnson. Per corrective action plan, staff was trained on how to properly supervise high risk residents and be updated on safety plans.


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

raw_content: A child expressed experiencing physical pain while being restrained.

Correction Narrative:
10/19/2022-The Licensed Administrator for Promise Rose Residential Care Home submitted a Corrective Action Plan identifying the action to achieve goal consisting of continuing to follow Child Care Licensing Minimum Standards for General Residential Operations.  Promise Rose will ensure that all staff are properly trained in PAPH/EBI.  According to the LCCA, a refresher course will be conducted on October 27, 2022, for all employees.

Additionally, the Program Director will ensure all sign-in sheets and certificates are completed during trainings.  The certificates will be filed in employees' files.

The training sign-in sheet will be submitted to licensing staff as evidence of compliance.

10/28/2022-The Licensed Administrator for Promise Rose Residential Care Home submitted a staff sign-in sheet for all employees participating in 4 hours of Trauma Informed Care training, 4 hours of EBI training as well as Cultural Diversity training conducted on October 27,2022 from 9AM until 5PM.  The trainings were instructed by the operation's Treatment Director, Executive Director as well as Program Director.

An inspection (#3915435) was completed at the operation on 11/16/2022. A walk-thru was conducted and interviews were conducted and determined to be compliant.


summary: 748.930(b)(4) - Annual Training- Caregivers must have 2 hours transportation safety training if caring for children younger than 9 yrs old.

raw_content: 4 of 4 staff files reviewed were missing 1 hour of the required annual transportation training.

Correction Narrative:
The Executive Director for Promise Rose Residential Care Home submitted a Corrective Action Plan identifying the action to achieve goal consisting of continuing to follow Child Care Licensing Minimum Standards for General Residential Operations.  Promise Rose will ensure that all staff are properly trained in two hours of transportation training instead of one.  A training will be conducted on June 23, 2022, for all employees.

Promise Rose Corrective Action Plan was created on June 15, 2022.

Additionally, the Program Director will ensure all sign-in sheets and certificates are completed during trainings.  The certificates will be filed in employees' files.

The training sign-in sheet will be submitted to licensing staff as evidence of compliance.

Promise Rose Executive Director submitted a sign-in sheet for all employees participating in PRRCH Annual Training on June 23,2022 from 8AM until 4PM.  The topics of training consisted of Supervision of High-Risk Youths, Housekeeping, Food, and Chemical Safety, Psychotropic Medication, and Transportation Safety.  Each topic was a two-hour training conducted by Promise Rose Program Director as well as Administrative Assistant.


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 member failed to use prudent judgment by locking a child in care outside of the home.

Correction Narrative:
A physical follow up took place at Young & Lockhart Elementary Schools. Three of 3 children stated they were not locked out of the home for no reason. The interviews are available in the Chronology.
The operation is requesting an admin review. ST
Ms. Nikia stated to go ahead and close the case out after speaking to the staff regarding the situation on 2/2/22.--CM