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

raw_content: The operation's policy does not state that a child's medication record should be updated within two hours of administering a child's medication.


state: TX

facility_name: Moving Forward Treatment Center

summary: 748.3001(C)(2) - Sanitation inspection- inspection unavailable must maintain documentation at operation and make available to us

raw_content: This standard is not addressed in the operation's policy.

Category: Safety and Emergency Practices

Standard Risk Level: Medium

Corrected at Inspection: No

Correction Narrative: The agency has a provided a copy of their updated policies and procedures to licensing with all of the required corrections. The policies have been reviewed and appear to meet compliance with minimum standards.


summary: 748.125(c)(1)(B) - Caregivers and employees must complete 1hr annual suicide training with curriculum that includes the understanding of safety planning.

raw_content: The operations policy indicates that staff will be required to take the AS+K training which only addresses the curriculum components for the risk factors, protective factors, and warning signs of suicide. Training must also address safety planning

Category: Organization and Administration

Correction Narrative: The agency has a provided a copy of their updated policies and procedures to licensing with all of the required corrections. These corrections were reviewed by a CCR Program Specialist and found to be compliant with minimum standards.


summary: 748.123 - Vaccine preventable policy - develop and implement written policy for vaccine-preventable diseases

raw_content: The operation does not have a written policy to address vaccine requirements (or lack thereof) for the employees.


summary: 748.345(1) - Electronic records policies - What records must be in external paper file and those that can be stored in electronic file

raw_content: The operation's policy does not state which records will be electronic and which records will be in external paper files.

Category: Reports and Record Keeping

Standard Risk Level: Low


facility_name: A Positive Change RTC LLC

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

raw_content: Documentation provided from the operation does not corroborate with the evidence provided by law enforcement. Observation log indicates a child in care was asleep while on runaway status as evidence confirms this information is inaccurate.

Category: Individual Standards Evaluated

Correction Narrative:
Operation provided the following compliance response:

A Positive Change (APC) sets policies and procedures for residents/staff to prevent injury, increase accountability, and avoid unnecessary crisis.

Documentation is also a part of policies and procedures as a method of ensuring that APC monitors and records all incidents of residents, staff, and that we are using best practices.

Upon arrival, the respectively assigned employee / employees note the facility clock time and obtain a Daily/Overnight Checklist as to document activities and behaviors of the resident that requires close supervision and/or 1:1 service. The respective staff and shift supervisor (if applicable) will review, approve, sign and submit the observation checklist to administration for final review and approval.

Moving forward, during orientation to the facility, as well as annually, staff will be taught strategies and techniques they can use to provide the best care, welfare, safety, and security for all.

Staff will document all incidents (physical and/or verbal), as well as teach residents to report to an adult (be a direct care staff, Case-manager, LCCA, etc.), while maintaining a safe and secure environment.

Failing to do so may result in staff being removed from work schedules pending results from investigation and/or allowed to work in another area under a safety plan.


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

raw_content: Evidence obtained confirms a child in care, who is on 1:1 level of supervision eloped from the operation approximately 1 hour prior to staff member's being aware of the elopement. Staff members account of the supervision of the child do not corroborate.

Standard Risk Level: High

Correction Narrative:
The operation provided the following compliance response:

1.	Staff will be re-trained on the APC 24hr supervision policy and each youths individual runaway prevention plan as well as the Trauma Informed Unauthorized Absence / prevention and protocols.
2.	When necessary, the residents will be placed on a safety plan signed by them, the therapist, Professional Level Service Provider, Licensed Child Care Administrator, and initial by all staff and their service plan will be updated, as well as notifying all parties in a timely manner.
3.	Staff must/will use prudent judgement when stationed in an area that prohibits direct line of sight; thus, compromising safety by asking a fellow staff member to tag out with them, informing them of the situation.
4.	Staff must/will use the documentation mentioned above/attached.

Moving Forward

During orientation to the facility, as well as annually, staff will be taught strategies and techniques they can use to provide the best care, welfare, safety, and security for all.

Staff will document all incidents (physical and/or verbal), as well as teach residents to report to an adult (be a direct care staff, Case-manager, LCCA, etc.), while maintaining a safe and secure environment.

Failing to do so may result in staff being removed from work schedules pending results from investigation and/or allowed to work in another area under a safety plan.

5/12/2025- Face to Face interviews were conducted with 2 residents at George Jr. High and Lamar Alternative School. A 3rd interview was attempted at Lamar Jr. High , however the resident refused to speak with me. Residents interviewed confirmed they enjoy their placement, there are no concerns regarding staff supervision. It was also stated they are never left alone, there are 3 staff on each shift and 1 of the 3 staff is for 1:1 supervision required for another resident at all times.


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

raw_content: Nine of nine medication logs evaluated only contained initials of the staff who administered the medication.  The operation didn't have documentation of the name and signature of the staff members who administers medication.

Category: Medication

Correction Narrative: On March 6, 2025, the operation provided the following response: To ensure optimal quality, efficiency, and adherence to standards as it relates to 748.2151(c)(6), A Positive Change RTC will implement the following measure. As part of the initial facility orientation process, new and prospective staff members who will be administering medication shall be trained on and required to initial and sign the MAR signature page.


facility_name: House of Hope Residential Treatment Center LLC

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 attempted to spit toward a child during a moment of behavioral escalation. The action did not result in physical contact; however, the behavior is inappropriate, unprofessional, and not consistent with Texas Minimum Standards.

Standard Risk Level: Medium High

Correction Narrative: House of Hope Residential Treatment Center provider a Behavior Management and De-Escalation Refresher Training, 1 hour for staff.


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

raw_content:
One medication log was missing the strength of the medication.

This citation was corrected at the time of inspection when the operation added the dosage to the document.

Corrected at Inspection: Yes


facility_name: Caring Companions LLC

raw_content: The operation provided inaccurate information about different incidents involving the children, as well as inaccurate documentation about restraints.

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

Correction Narrative: On 02/20/26 The operation submitted a compliance plan stating that it will implement a documentation system to ensure accuracy and consistency. The administrator will be responsible for ensuring compliance. Additionally, on March 8, 2026, all staff will undergo retraining on how to accurately complete documentation, including serious incident reports and forms.


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

raw_content: The unauthorized absence of two children in care was not reported timely.

Correction Narrative: Caring Companions advised they will notify licensing in a timely manner required by minimum standards of the child 13 yrs old or older for an unauthorized absence. Licensing will receive documentation of the incident. Which will include what happened, when it happened, and who were notified of the incident and the follow-up. Licensing will also be updated when the child returns to the facility or incarcerated.


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: Two legal guardians of the children in care were not notified timely about the unauthorized leave of absence.

Correction Narrative: Caring Companions advised they will notify parents in a timely manner required by minimum standards, of a child 13 years old or older of unauthorized absence. Parents will receive documentation of the incident. Which will include what happened, when it happened, and who were notified of the incident and the follow-up. The parent will also be updated when the child returns to the facility or incarcerated.


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 completed its annual fire inspection on time; however, the operation did not pass the inspection.  The operation must address and correct all identified code violations to achieve compliance.

Correction Narrative:
On January 14, 2026, the RCCR inspector followed up with the operation regarding their fire inspection. The owner responded on January 15, 2026, stating that the corrections pointed out by the fire marshal had been completed. The owner said they passed the inspection and were told by the fire marshal that it would take up to two weeks to receive the documentation once the official Inspection takes place.

02/05/26 - The RCCR Inspector was informed by the fire marshal's deputy that the official re-inspection can be scheduled after the updated fire permit receives final approval. The deputy explained that this process may take some time.

02/20/26 - The owner of the operation submitted the fire inspection report and the sprinkler system inspection report that took place on 02/20/26, reflecting a passing code for fire and safety and the resolved violations.

The RCCR inspector requested that the report be submitted for review once it is available.


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: A staff member disclosed to law enforcement that a child was restrained with their hands behind their back.

Correction Narrative:
RCCR conducted an unannounced follow-up inspection at the operation. Documentation was obtained regarding required staff completing a refresher training in De-Escalation, Crisis Prevention, and Restorative Intervention.  Additionally, a meeting/training was conducted to discuss Trust Based Relational Intervention. RCCR also spoke with four staff regarding the meeting and refresher, and no concerns were noted.

10/22/25 - The CEO of the operation stated that the operation's staff will receive additional training on approved personal restraints to ensure the use of accurate and appropriate restraints, as well as to make them aware of prohibited restraints.


raw_content: Documents provided, such as serious incident and restraint report did not include all required components and information was observed to be missing or not documented.

Correction Narrative:
RCCR conducted an unannounced follow-up inspection at the operation and confirmed that the files are being audited by administration. Additionally, documentation was obtained reflecting changes that the operation has implemented via a revised resident audit form. Documentation was reviewed for the serious incident report and restraint report, and no concerns were observed.

10/22/25 - The CEO of the operation stated that an audit system will be implemented for the review of documents to ensure accuracy and consistency. This audit system will be implemented every two weeks, and training will be provided to staff on how to accurately fill out serious incident reports and forms.


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

raw_content: During inspection inspector was notified the treatment director had recently left the operation. This time the operation does not have a treatment director.

Category: Personnel

Correction Narrative:
On July 25, 2025, the CEO stated that the facility is actively searching for a treatment director. A post was published on WorkSource and other platforms to fill the position.

On August 14, 2025, the CEO sent an email with information about the new Treatment Director appointed by the operation.


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

raw_content: It was determined staff showed as active status since 03/30/25, however this staff was never employed by the operation

Correction Narrative: The CEO has indicated that the operation has conducted a comprehensive review of all submitted background checks and has taken the necessary steps to deactivate any employees who are no longer associated with the facility. Furthermore, the administrator will conduct weekly audits to ensure that all disassociated staff or Non interested employees have been inactivated within the required timeframe.


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: The child records reviewed during inspection did not include the child orientation. The operation could not provide the child orientation.

Category: Admission, Service Planning, Discharge

Standard Risk Level: Medium Low

Correction Narrative:
On August 13, 2025, the CEO stated via email that the operation will ensure all required topics are discussed during the resident orientation. This will ensure the children are aware of their rights and the facility's expectations. The staff responsible for going through the orientation handbook with the child will ensure they go through the entire handbook. The CEO also stated that the handbook will be available to all residents who would like to review it or have questions. CC created a checklist to ensure that all orientation subjects are discussed with children at the time of admission. Additionally, staff will conduct a monthly audit to ensure all required documentation is readily available when requested.

The CEO provided copies of the resident orientation handbook and the checklist that will be used during intake to ensure that all required documentation is completed. All required topics from the orientation were included in the audit form.


raw_content: An employee that was no longer employeed since the beginning of May still shows active.

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

Correction Narrative:
The operation has indicated that the administrator or designee will be responsible for inactivating individuals who no longer work with the operation. This task will be completed within seven days after the individual is no longer associated with the operation.
The operation indicates that the administrator or designee will be provided with training on the expectations and standards for background check validation as needed if the compliance is not being met. Furthermore, the administrator, manager, or supervisor will conduct an audit of all former employees within seven days of the termination of their employment.


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

raw_content: An admission assessment was observed to only have the resident's name and date.

Correction Narrative:
On May 28, 2025, the operation provided the following response: Admission Assessment will be completed, signed and dated by the service provider on the date of assessment.
If compliance is not met the Service provider will receive proper training from the administrator/ manager on the expectations and standard for admission assessments.
The administrator/manager will be responsible for ensuring the admission assessment is completed, signed and dated by the service provider.
An audit will be done by the administrator/manager/supervisor on all resident placement paperwork one week after a resident is placed in the facility. This will be put in place so no further citations will be given for this standard and any similar standards. A routine monthly audit will also be done to ensure all paperwork is complete and accurate.


summary: 748.709(c) - Name of each designated person must be documented on the face sheet of the child's record

raw_content: Resident face sheet indicates a terminated employee is the normalcy designee.

Correction Narrative:
On May 28, 2025, the operation provided the following response: The face sheet will be updated when personnel or designated persons have changed for the child's record.
The face sheet will be changed to show accurate information for the child's records as personnel or designated persons change on the caseload.  If compliance is not met the case manager/supervisor will receive proper training from the administrator/ manager on the expectations and standard for the face sheets of the residents. The administrator/manager will be responsible for ensuring the child's face sheets are updated and current. A meeting will take place to ensure all personnel that are responsible for paperwork are aware of any and all changes, such as termination of an employee. This allows for all paperwork to be updated in a timely manner.
An audit will be done by the administrator/manager/supervisor on all resident's paperwork after there are any changes in personnel or designated persons for the child. This will be put in place so no further citations will be given for this standard and any similar standards. A routine monthly audit will also be done to ensure all paperwork is complete and accurate.

Additionally, the operation corrected the face sheets and submitted them to Licensing.


raw_content: Discrepancies were observed in the admission assessment that was evaluated. The front page of the admission assessment is dated 04/29/2025 as the date of the assessment.  However, the second page states that the date of the assessment is 11/29/2022 and the expected or actual placement date is 11/29/2022.  Additionally, the documentation, on page 7, references a different operation will be meeting the needs of the child instead of the current placement.  Similar discrepancies were also observed in the preliminary service plan.

Correction Narrative:
On May 28, 2025, the operation provided the following response: The Admission Assessment will be completed with true and accurate information with complete records of the child's information.
If compliance is not met the case manager will receive proper training from the administrator/ manager on the expectations and standard for admission assessments and the accuracy of the child's records and information.
The administrator/manager will be responsible for ensuring the child's records are accurate and current.
An audit will be done by the administrator/manager/supervisor on all resident placement paperwork one week after a resident is placed in the facility. This will be put in place so no further citations will be given for this standard and any similar standards. A routine monthly audit will also be done to ensure all paperwork is complete and accurate.


facility_name: Brooklow's House LLC

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

raw_content: Incidents pertaining to a child being arrested were not documented.

Correction Narrative: The operation ceased operation and had no children in care as of 06/06/25.


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

raw_content: An arrest that occurred on 05/28/25 was not reported to Licensing until 05/30/25.

Correction Narrative: The operation ceased operating and had no children in care as of 06/06/2025.


raw_content: The employee roster provided to Licensing was found to be inaccurate, as it included six individuals who are no longer active employees.


summary: 748.303(a)(6)(B) - Serious Incident-Report to parents as soon as facility aware that child is indicted, charged, or arrested

raw_content: Notification to the child's DFPS Caseworker was not made at the time of the child's arrest, as required.


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

raw_content: Inspector requested records several times and did not receive the documents.The operation had closed and ceased operations as of June 6, 2025.


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

raw_content: It has been indicated the 1:1 ratio of one youth and the 2:5 ratio of another youth was not followed evidenced by one staff member being left alone to work on shift.

Correction Narrative: The operation is closed and is no longer caring for children.


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

raw_content: A staff member admitted to sleeping during the night when he was supposed to be supervising the children in care.

Correction Narrative: The operation ceased operating as of 06/06/2025.  No children are in the care of the operation.


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

raw_content: A staff member was seen on video to push a child in care and not maintain self-control of her actions when caring for the child in placement.

Correction Narrative: Brooklow's House LLC (Operation # 1797609) ceased operations on June 6th, 2025. The standard shows that it is waived at this time.


summary: 748.685(b)(4) - Caregiver responsibility - when deciding how close to supervise take into account the surrounding circumstances, hazards, and risks

raw_content: A small shelf / TV stand was blocking the doorway in a bedroom.


summary: 745.8411(b)(4) - Responsibilities - Not delay or prevent inspection or investigation

raw_content:
Not all records are accessible during inspection.

3-18-25 Not all records were accessible during the visit.

Correction Narrative: The operation administrator since 2-25-25, Tamika Burns, provided the required documents as requested for this inspection. The administrator informs a more systemic system will be placed to provide documents during a visit and in a timely manner.


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

raw_content: A child sustained a black eye, and the child indicated he did not get offered medical care.


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

raw_content: A staff member was unable to implement a restraint which resulted another child to be hit several times.


summary: 748.311(7) - Serious Incident Documentation-Includes circumstances surrounding the incident

raw_content: The incident report did not provide full detail of what occurred only that there was an altercation. It did not provide information about medical care and law enforcement information. It did not include information if the boys were separated, full outcome, or de-escalation.


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

raw_content: The operation failed to provide an AWOL log that documented all of the annual unauthorized absences.

Correction Narrative: This operation is closed as of 6/6/25 per the operation inspector. An AWOL log is no longer required.


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

raw_content: The refrigerator and the freezer are missing thermometers.


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

raw_content: Food items in the pantry are stored on the floor.


summary: 748.1219(4)(B)(i) - Treatment Services Admission-Psychiatric evaluation or psychological evaluation must include the child's diagnosis if applicable

raw_content: A child chart did not contain the psychological evaluation required for behavior issues.


raw_content: Not all records are accessible during inspection.

Standard Number / Description: 745.8411(b)(4) - Responsibilities - Not delay or prevent inspection or investigation


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

raw_content: Child charts did not indicate religion preferences.


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

Deficiency Narrative: A child sustained a black eye, and the child indicated he did not get offered medical care.

Correction Narrative:
Brooklow's House LLC (Operation # 1797609) ceased operations on June 6th, 2025. Administrative Reviews are still pending.

RCCR will cite for standards not receiving corrective action in a timely manner. Operation was notified during the exit for this investigation, telephone call, and via
email on 3-6-25.

RCCR PA reviewed and there is no administrative review noted, and the operation is closed and is not providing services for children in care at this time. The Minimum Standard is waived and compliance is met due to the operational status at this time.


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

Deficiency Narrative: A staff member was unable to implement a restraint which resulted another child to be hit several times.


Standard Number / Description: 748.311(7) - Serious Incident Documentation-Includes circumstances surrounding the incident

Deficiency Narrative: The incident report did not provide full detail of what occurred only that there was an altercation. It did not provide information about medical care and law enforcement information. It did not include information if the boys were separated, full outcome, or de-escalation.


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

raw_content: Operation does not have preliminary service plans


raw_content: Record was not presented within a timely manner.

Standard Number / Description: 748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction


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

raw_content: Emergency behavior intervention policy or practices not included in orientation.


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

raw_content: Did not find when orientation was given to children.


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

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


summary: 748.1209(b)(9) - Child Orientation-Include policies on the educational program

raw_content: Education program policy not included in the orientation


summary: 748.1209(c)(2) - Child Orientation - Include information on how to contact parties to child's case-i.e. caseworker, attorney/guardian ad litem, CASA

raw_content: Information on how to contact parties to a childs case not found in orientation


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

raw_content: Multiple medication logs did not have the dosage of the medication


summary: 748.1205(a)(4) - Admission Documentation-Includes names, addresses, telephone numbers of siblings

raw_content: Sibling information not found in documentation


summary: 748.1209(b)(7) - Child Orientation-Include policies on discipline

raw_content: Discipline techniques or practices not included in the orientation


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

raw_content: Medication record not updated within the appropriate time frame. Medication log missing dates logged.


summary: 748.1205(a)(3) - Admission Documentation-Include names, addresses, phone numbers of bio or adoptive parents, unless parental rights terminated

raw_content: Parents information not found in admission documentation.


summary: 748.1209(b)(10) - Child Orientation-Include policies on trips away from the operation

raw_content: Policy on trips away from the operation not included in the orientation.


summary: 748.1217(b)(11) - Admission Assessment-At admission, must include documentation of efforts to obtain required information, if any information is not obtainable

raw_content: Efforts to obtain information not found in admission assessment.


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

raw_content: Information on how to make complaints to outside agencies not found in orientation


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

raw_content: A child in care with a history of unauthorized absences was left outside unsupervised.


summary: 748.3233(b)(4)(C) - Evacuation-Emergency evacuation & relocation diagram includes at least 2 exit routes that are not through a kitchen or other hazardous area

raw_content: Relocation diagrams downstairs go through the kitchen.

Correction Narrative: Operation provided a copy of the exit routes not going through the kitchen.


summary: 748.753(a)(1) - Pre-Employment Screening-You must complete reference checks by obtaining the name and contact info of two individuals who can serve as references.

raw_content: An employee did not have a reference checks.

Correction Narrative: Corrections were received from the operation. The operation will complete an internal audit on employee files to ensure references are in files. The Administrator will also implement a tracking system.


summary: 748.605(a) - Treatment director-must meet specific professional qualifications if prevalent population has intellectual disabilities or autism spectrum disorder

raw_content: Qualifications for the treatment director were not provided.

Correction Narrative: Corrections were received from operation. The operation will review and document the treatment directors' qualifications. The operation will complete an internal audit to review employee files.


summary: 748.505(b)(6) - Minimum qualifications for employees- Must have cleared pre-employment screening assessment.

raw_content: An employee file did not have the pre-employment screening in their file.

Correction Narrative: Corrections were sent in by the operation. The operation completed a review on employee files to ensure all required documents are in files. The administrator will be responsible to ensuring that employee files have the required documentation.


summary: 748.363(4) - Personnel records-Personnel records-Include current job description.

raw_content: An employee file did not have their job description.

Correction Narrative: The operation sent corrections. The operation will conduct a review of existing review of employee files and include a tracking system. The administrator will ensure that employee files have their required documents.


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

raw_content: Records were not available for review upon request.

Correction Narrative: The operation sent the employee file. The operation will nnsure all active records are organized and accessible for review. The LCCA will maintain and update the records. The operation will implement a checklist to ensure compliance.


summary: 748.3113(a) - Fire Extinguisher-Must have a fire-extinguishing system, which may be sprinkler system and/or fire extinguishers

raw_content: There was no fire extinguisher at the operation.

Correction Narrative: The operation sent photos of the fire extinguisher installed. The operation will conduct monthly inspections to ensure the fire extinguishers are functional and properly maintained.


summary: 745.621(a)(1) - Initial background checks submitted - At the time you submit your application

raw_content: There were two employees who did not have background checks.

Correction Narrative: The operation completed background checks on the missing employees. The operation will complete a pre-employment background check process prior to begin working.


facility_name: Her Heart Can

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

raw_content: The staff file reviewed during the last inspection still does not have the documentation of the pre-employment affidavit on file.  An additional staff file reviewed during today's inspection also did not have documentation of the pre-employment affidavit.


summary: 748.1757(b) - AP Prohibited for infants-Crib must be bare except for tight fitting sheet & crib mattress cover per 748.1757(c) for infant less than 12 months

raw_content: During the walk through of the operation, an infants crib did not have a tight fitting sheet.  A bottle was also observed in the crib.

Correction Narrative: The cribs were observed with tight fitting sheets and no additional bottles, etc in them.


summary: 748.505(b)(3) - Minimum qualifications for employees-Physically, mentally, emotionally capable of performing assigned tasks; has the necessary skills

raw_content: The staff that was lacking documentation in the file showing the caregiver had the necessary skills is still lacking .

Correction Narrative: The lacking documents are now in the staff file.


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

raw_content: In the last seven weeks, the documentation reflects the treatment director not being full time.

Correction Narrative: The treatment director has clocked in/out full time for the last week.


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

raw_content: During the review of files at the inspection, the files were not complete.  This was demonstrated the management staffing finding documents, printing, and placing the documents in the files.

Correction Narrative: The requested documented were in the files.


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

raw_content: A drive was allowed to transport at least one youth in care with an expired drivers license.

Category: Transportation


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

raw_content: During the time of the incident, there were 1 staff and six children. The operation also had a baby in the home at the time as well. The operation has a treatment director and has children in care that requires treatment services.


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

raw_content: During the incident, staff did not intervene appropriately which led to children being injured at the facility.

Correction Narrative: The owners conducted extra training with all staff regarding supervision expectations.  The operation has a scheduled staff meeting to discuss supervision as well as management conducting additional random checks of the staff.


summary: 745.4151(c)(8)(B) - Documentation-Drug test results must be kept for one year after employee's last work day or until any investigation involving person is resolved

raw_content: One of two caregiver's file did not the results of the drug testing.

Correction Narrative: The operation emailed the missing document.  The drug test was dated 01/16/2025.


raw_content: The administrators' timecards reviewed did not include accurate information reflected.


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

raw_content: There has not been a full-time administrator at the operation two of four weeks based on timecards reviewed.

Correction Narrative: The operation is currently without an administrator.


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

raw_content: One of two caregiver files reviewed did not have an affidavit on file.

Correction Narrative: The operation emailed the missing document.  The affidavit was dated May 1, 2024.


raw_content: One of two caregiver files reviewed did not have documentation showing the caregiver had the necessary skills.

Standard Number / Description: 748.505(b)(3) - Minimum qualifications for employees-Physically, mentally, emotionally capable of performing assigned tasks; has the necessary skills


raw_content: One of two caregiver files reviewed did not have documentation of the pre-employment affidavit on file.

Standard Number / Description: 748.505(b)(5) - Minimum qualifications for employees- Must complete a Pre-Employment Affidavit for Applicants for Employment.


raw_content: One of two caregiver's file reviewed did not have documentation showing the pre-emoloymeent screening assessment.

Standard Number / Description: 748.505(b)(6) - Minimum qualifications for employees- Must have cleared pre-employment screening assessment.

Correction Narrative: The lacking pre-employment screening has now been completed and in the staff person's file.


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 operation failed to notify RCCR of the unauthorized absence of two youth in care.

Correction Narrative: The operation called and made the report of the unauthorized absence.


raw_content: There has not been a full time administrator at the operation for the last two of four weeks.

Standard Number / Description: 748.531(a)(3) - Child-care administrator-Is full-time employee of the operation


raw_content: The operation was not able to provide verifiable proof that the administrator is working full time at the operation.


summary: 748.751(b)(2) - Pre-Employment Screening-You must document the results of any contact with an applicant's previous employers in the personnel file.

raw_content: In the two staff file reviewed both had only one of the previous employers contacted to verify employment.

Correction Narrative:
5/16/25: The owner emailed information regarding one of the employee's references.

5/21/25: The owner emailed additional information for the 2nd employee.

5/23/2025: The required information was verified during the onsite inspection #4058453.


summary: 748.605(c) - Treatment director-must meet specific professional qualifications if most prevalent population is children with emotional disorders

raw_content: The named treatment director does not have documentation on file showing they meet the specific educational/professional qualifications.


summary: 748.753(a)(1) - Pre-Employment Screening-You must complete reference checks by obtaining the name and contact info of two individuals who can serve as references.

raw_content: One of the staff file reviewed during the inspection did not include the required two references.


raw_content: Based on the weekly schedule and timecards, the LCCA is not a full-time employee of the operation.


summary: 748.563(a) - Professional level service provider-meet specific qualifications if operation provides certain amount of treatment services for emotional disorders

raw_content: The PLSP file reviewed did not have documentation showing they meet the qualifications requirements.


summary: 748.1703(a) - Menus-must maintain daily menus showing all meals and snacks that the operation prepares and serves

raw_content: During Walkthrough of the operation, it was discovered that the menu was not completely filled out and substitutions were not offered (Standard 1703 b).


raw_content: There are 3 runaway reports on the unauthorized absence log that indicate children were away from the operation more than 6 hours. The reports were not received timely and or documentation of the unauthorize absence log is incomplete.

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

Correction Narrative: The operation submitted a plan of correction the included updated policies to clearly align with the standards.   Also, all staff completed mandatory refresher training on reporting.  The operation also plans to do ongoing scenario-based reporting drills quarterly.


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

raw_content: A child in care was arrested from school. This was not reported.


summary: 748.453(a)(2) - Unauthorized Absence - Annual summary log must include time and date absence was discovered

raw_content: The unauthorized absence log did not include the time the absence was discovered by the staff on two of two occasions, the hotline report number for one of two occasions nor information on the length of time the youth was missing or if the youth returned on two of two occasions.

Correction Narrative: The owner emailed the updated completed unauthorized absence log with all required items listed.


summary: 748.363(2) - Personnel records-Include documentation showing that the person meets minimum age and qualifications for the position

raw_content: One of two staff records reviewed, did not detail how the staff was qualified for their role at the operation.

Correction Narrative: The owner emailed an updated job description with lesser educational requirements.


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

raw_content: During the outside walk through, sharp items and sharp glass was observed on the ground, near the barn.

Correction Narrative: The owner emailed photos of the cleaned area now of the spots where the glass and sharp objects were during the inspection.


summary: 748.831(b) - Orientation-Document the completion of the orientation in the appropriate personnel record

raw_content: In one of two staff records reviewed, dates are missing from training documentation, unable to verify if pretraining was completed within 90 days of beginning job duties.

Category: Training and Professional Development

Correction Narrative: The operation emailed the completed orientation statement with dates listed for the staff records that had been missing during the inspection.   Compliance met


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

raw_content: A caregiver is showing active in the operation people list, the caregiver has not been employed with the operation for twenty days.

Correction Narrative: The background check has been inactivated by the operation.


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

raw_content: The operation has allowed two individuals access to children in care without received the eligibility notification.


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

raw_content: During today inspection, the well house was in need of maintenance.

Category: Physical Site

Correction Narrative: The operation emailed an updated photo of the well house with the repairs made and a latch re-installed.


summary: 748.4111(b)(1) - Transportation records-Must maintain the insurance verification in the vehicle

raw_content: At the time of the inspection, the operation did not have insurance for the vehicle being used to transport the children in care.

Correction Narrative: The insurance card submitted via email on 02/17/2025 had effective date of 02/17/2025 - 02/17/2026 as a temporary card.


summary: 748.303(b) - Serious Incident-Not required to report medically pertinent incident if not level of serious incident. Document same as a serious incident

raw_content: A serious incident report was not completed for a medical event that occured at the operation.


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

raw_content: The operation has admitted a child in care that does not meet the operation's admission policy.

Correction Narrative: The owner and LCCA emailed the updated admission policy to include girls, both pregnant and not pregnant.


raw_content: During today inspection, several items were in need of maintenance.

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


summary: 748.103(b)(4) - Policies and procedure to submit - Admission

raw_content: Operation is getting licensed for girls only, and biological girls that are currently pregnant, policies did not state this.  The application indicates children ages 14-17 are admitted, however the policy states ages 7-17.

Correction Narrative: The operation emailed the updated policies.


summary: 748.3313(2) - Water-May use private water system if operation keeps records indicating water supply meets Texas Commission on Environmental Quality requirements

raw_content: The water quality test was not done for the private water supply.

Correction Narrative: The water quality test has been completed.


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

raw_content: One bathroom sink had a crack in the bowl that was leaking in the under cabinet.

Correction Narrative: The crack in the sink in bathroom #1 has been repaired and is no longer leaking.


summary: 748.125(d)(4)(b)(i) - Suicide Screening- Must be conducted at admission for children under 10 yrs if info. given at admission shows a history of suicide attempts/thoughts.

raw_content: The policy did not address any of the standards regarding children under the age of 10.

Correction Narrative: The operation emailed the completed updated policies.


summary: 748.125(c)(2) - Suicide Training-You must promote suicide prevention training for non-employees, as appropriate.

raw_content: There was no policy that included this information.


summary: 748.3107(a)(2)(A) - Smoke Detector-If no fire inspector available to give location recommendations, smoke detectors located in hallways/open areas outside bedrooms

raw_content: There was a smoke detector outside of one of the bedroom.

Correction Narrative: A smoke detector has been added to room #4.


summary: 748.103(b)(6) - Policies and procedures to submit - Emergency behavior intervention

raw_content: The written EBI policies did not meet standard 748.2801(2)(A), 748.2901(a)(2) or (B), 748.113(a)(v), (viii), (ix) or (6).


summary: 748.103(b)(3) - Policies and procedures to submit - Conflict of interest

raw_content: Conflict of interest policies did not meet the requirements of 748.107(1) and (2).


summary: 748.103(b)(13) - Policies and procedures to submit - Tobacco and e-cigarette

raw_content: The tobacco policy did not address smoking in the vehicle.


summary: 748.3391(c) - Bathrooms-Child must not have to cross a common use room to access a bathroom from the child's bedroom

raw_content: Bedroom #4 did not have direct access to a bathroom without having to cross activity spaces.

Correction Narrative: A hallway has been built for room #4 to access the bathroom.


summary: 748.103(b)(1) - Policies and procedures to submit - Related to record keeping, including where records will be located.

raw_content: Several policies violated the requirements of 748.303 and 748.313.  Further there were no policies for record storage in regards to SIRs.


summary: 748.125(g)(1)(A) - You must create a Postvention Team, Written Action Plan and Protocols.

raw_content: The suicide postvention written plan did not include the required items in 748.125(g)(B)(i) (I-VI).


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

raw_content: A trailer was observed in the back yard with nails sticking up that could become hazardous to youth in care.

Correction Narrative: A trailer that was observed in the back yard has been removed.


summary: 748.101(3) - Plans to submit - sketch of operation's floor plan

raw_content:
The diagram did not include the designated location in the case of fire.

The diagrams were fixed during the inspection.


facility_name: Forever Home Foundation LLC

summary: 748.1385(2) - Service Plan Review-Must identify any new needs and strategies or techniques to meet these needs, including instructions to employees

raw_content: Service plan reviews completed on 10/12/2025 and 01/11/2026 do not reflect any documentation for transitioning to adulthood for 14 years and older.

Correction Narrative:
An email was received with corrective action indicating all Service Plan Reviews will be reviewed and approved by the Program Director or Administrator prior to finalization, annual refresher training on Service Plan development and review requirements
will be conducted for all case management and supervisory staff, and failure to complete compliant Service Plan Reviews will result in corrective coaching and, if necessary, progressive disciplinary action.


summary: 748.125(d)(4)(D) - Suicide Screening- Must be administered every 90 days after admission for children 10 years of age or older in a GRO that is not a RTC.

raw_content: Two of two child files review did not have records to show that Suicide Screens are being completed every 90 days.

Correction Narrative: On 11-27-25 The operation submitted a CAP for this Citation. Suicide Screens were completed with all children. Staff were given a training; Administrator will conduct monthly audits.


summary: 748.751(a)(1) - Pre-Employment Screening- You must obtain in writing an applicant's employment history before hiring.

raw_content: Five of Five employee files reviewed have no record of the employees five years employment history.

Correction Narrative: On 11-27-25, the operation submitted a CAP. The operation has created a pre-employment packet with a check off list. HR staff was given a training regarding the standard. Administrator will review and approved new hires.


summary: 745.621(a)(3) - AP Initial background checks submitted - At the time you contract with someone who requires a background check

raw_content: A background check for contracted therapist was not submitted prior to allowing the individual to be present at the facility.

Correction Narrative: On 7-4-25 the Administrator submitted a CAP, which stated that moving forward all service providers will require a background check regardless of their credentials. The service providers will also be required to sign an agreement of understanding having to do with what they are allowed to do or not to do in during a crisis. INSPECTION # 4065792


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

raw_content: Two of Two records reviewed for the children in care with the operation are missing their Admissions Assessments.

Correction Narrative: On 3-31-25, the CEO Ashly Johnson submitted the operations CAP along with proof of TB tests for four employees. Ms. Johnson stated all employees will be informed that TB testing is a requirement for employment. Ms. Johson stated as CEO she will review all new placement files to ensure admission assessments are completed.


summary: 748.363(6) - Personnel records- Include copy of a cleared tuberculosis screening conducted prior to the person having contact with children in care.

raw_content: Four employee files were reviewed and found to be missing proof of TB tests.


summary: 748.103(a) - Policies & procedures to submit-must comply or exceed Chapter 42 of HRC, Chapters 745,748,& all other applicable laws and rules

raw_content: There are no policies and procedures in place regarding emergency services.

Correction Narrative: Policies and procedures have been created and added regarding emergency services.


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

raw_content:
Suicide policies did not include how the operation will immediately implement a suicide screen if child exhibit
warning signs.

Correction Narrative: Operation updated polices to induce how the operation will screen children if they exhibit any warning signs of suicide.


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

raw_content: Suicide polices does not include the procedure as to how the operation will report to licensing.

Correction Narrative: Operation updated polices to reflect changes that include the procedure the operation will take when reporting a suicide attempt by a child.


summary: 748.3351(3) - Interior Space-Provide 40 sq feet of indoor activity space per child, including adult residents and children of caregivers residing at the operation

raw_content: Operation does not have required living space for minimum capacity for a General Residential Operation.

Correction Narrative: Operation made physical site changes to expand living area which consists of a study room that allows the operation to have enough living space for a total of 7 children.


raw_content:
Common restroom does not provide privacy for children as children would need to pass through kitchen and living
room area to access restroom.

Standard Number / Description: 748.3391(c) - Bathrooms-Child must not have to cross a common use room to access a bathroom from the child's bedroom

Correction Narrative: Physical changes have been made so that children have direct access to restroom without having to pass through the kitchen or living room area.


facility_name: Helping Each Other LLC

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: Operation did not provide up to date sanitation inspection.


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

raw_content: Review of the medication logs were not found to be complete and accurate. There were missing dates, times, and signatures.

Correction Narrative: A corrective plan was received via email by the operation on 4-9-26. The LLC at that time implemented staff are required to document the date, time and signature immediately after each medication is administered. The lead staff will conduct weekly reviews of medication administration records to ensure all entries are complete and accurate.


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

raw_content: Review of the medical records shows that staff did not administer the medications as prescribed for each child.

Correction Narrative: The operation responded via email with a corrective plan to ensure medications are administered according to the prescribing health-care professional. LLC will implement individual medication administration schedules for each child. Staff will be trained on following physician orders and verify correct medications, dosage and timing prior to administration. Training is to take place on March 19, 2026.


summary: 748.153(3)(A) - Notification - Change in child-care administrator

raw_content: Operation did not notify licensing that the administrator had resigned.

Correction Narrative: Operation has corrected the deficiency by hiring another administrator. Operation has been made aware of the importance of keeping constant communication, operation is in agreement that they will communicate any changes made to licensing as soon as they are made aware to ensure compliance.


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

raw_content: Operation staff subjected children in care to language that is considered humiliating, shaming, ridiculing, or rejecting.

Correction Narrative:
Helping Each Other LLC will ensure that no staff member uses humiliating, shaming, ridiculing, rejecting, or inappropriate language toward children in care. All staff will receive refresher training on prohibited disciplinary practices and appropriate communication with children. All staff members will sign a training roster that will be kept in the Administrative Office for review.  The LCCA will reinforce expectations for respectful interactions and will address any violations through corrective action in accordance with Helping Each Other policy to ensure children are treated with dignity and respect at all times.

Operation has provided training log to prove corrections have been made and risk has been mitigated.


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 members locked two children out of the facility after their elopement.

Correction Narrative:
Helping Each Other LLC will ensure all staff demonstrate competency, prudent judgment, and self-control while supervising children and performing assigned duties. All staff will receive immediate retraining on appropriate supervision practices, crisis response, and professional conduct, including the proper handling of elopement and behavioral incidents. All staff members will sign a training roster that will be kept in the Administrative Office for review. The LCCA will reinforce expectations during staff meetings and will monitor staff performance to ensure compliance. Any staff who fail to demonstrate appropriate judgment or self-control will be subject to corrective action in accordance with Helping Each Other policy.

Trainings have been reviewed and deficiency has been corrected.


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

raw_content: The operation provided a special service to a child not listed on the operation's permit.

Correction Narrative: Helping Each Other LLC will ensure that only children whose needs can be met by the operation and who are approved under the operations permit are admitted or provided services. The Treatment Director or LCCA will verify each childs admission eligibility, service needs, and permit authorization prior to admission or the provision of any special services.


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: The agency did not report the incident to the parent in the needed timeframe.

Correction Narrative: Staff will be retrained on timely reporting.


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 agency did not report the absence of a child to licensing in the needed timeframe.

Correction Narrative: Staff will be retrained on timely reporting to licensing.


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

raw_content: The operations' serious incident report did not have a section listed for contacts made, and thus information was missing and unable to be verified.

Correction Narrative: HHSC Form 2991 will be adopted.


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

raw_content: Employee does not have notarized affidavit employment form.

Correction Narrative:
Operation corrected the deficiency by providing a singed document of the affidavit of employment.
Operation submitted the updated form via email. Administrator Amy Garza submitted the information.

The corrective plan of action states that  The Administrator/Administrator Assistant will review all employee files and ensure the affidavits along with required documentation are fully completed during the onboarding process. The Administrator/Administrator Assistant will ensure the Pre-Employment Screening forms are completed as stated in minimum standards, before the employee is fully employed.


facility_name: West Texas Boys Ranch

raw_content: In a review of this investigation, it was found that a caregiver confronted and yelled at a child regarding allegations the child made toward the caregiver.

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

Correction Narrative: RCCR inspector Bianca Reyna received a compliance memo from the West Texas Boys Ranch Chief Compliance Officer on 3/30/2026. A training regarding standard 748.2307(8) was provided to all staff and cottage parents and the signature sheet was provided.


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

raw_content: In a review of employee files, 2 staff records did not have an annual training completed for normalcy.

Correction Narrative: A compliance email was received on 10/13/2025, from the West Texas Boys Ranch Chief Compliance Officer, with two staff certificates for a two-hour normalcy training taken on 10/08/2025.


raw_content: In a review of records, 2 staff files were observed to have the notorized affidavit signed approximately 5 months after the date of hire.

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

Correction Narrative: A compliance email was received on 10/13/2025, from the West Texas Boys Ranch Chief Compliance Officer, with a memo stating that a discussion regarding notarized affidavits being signed and notarized prior to employment was conducted with the administrative assistant on 10/09/2025.


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

raw_content: In a review of employee files, 2 staff did not have an annual training completed for trauma informed care.

Correction Narrative: A compliance email was received on 10/13/2025, from the West Texas Boys Ranch Chief Compliance Officer, with two staff certificates for a two-hour trauma informed care training taken on 10/09/2025.


summary: 748.1101(b)(3)(C) - Children's rights-Adhere to the child's rights to have religious needs met

raw_content: In a review of the abuse/neglect investigation, it was found that a child was denied of their right to worship/attend church as a form of punishment for not completing tasks and chores.

Correction Narrative: A compliance email was received from the operation's chief compliance officer on 11/03/2025, with an attached training sign in sheet for staff that was held on 10/28/2025 regarding child's rights/religious needs.


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

raw_content: A child in care was left unattended resulting in an injury involving a horse.


summary: 748.1101(b)(3)(K) - Children's rights-be informed of search policies and be free of unreasonable searches and unreasonable removal of personal items

raw_content: The child's rights form and the intake packet for the operation did not include information regarding searches.

Correction Narrative: Mr. Childress (WTBR chief operations officer) provided the following documents via email on 12/03/2024: the operation's updated child's rights form, intake packet, placement agreement, and search policy acknowledgement form for the operation to include information regarding searches.


summary: 748.1113(c)(1) - Child Rights searches-RTC or emergency care services program may conduct routine searches if justified in operation policies

raw_content: The operation is a GRO and their policies do not permit routine searches. Multiple children and house parents stated the children are searched routinely after school.

Correction Narrative: Mr. Childress (Chief operations officer) sent an email follow up on 12/03/2024, with WTBR policy on conducting searches when there is a reasonable suspicion of prohibited items, items that endanger child safety, if child has made suicidal threat or threatened to harm self or others, if a child involved in theft, and after home visits.


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

raw_content: Two cottage parents are no longer employeed but still have an active background check.

Correction Narrative: The inspector received an email from the Program Director on 11/14/23 stating inactive employee BGCs have been inactivated. An online BGC check confirmed that the 2 cottage parents were inactivated.


summary: 748.863(a)(2) - If EBI not allowed, caregivers for childcare prog. or treat. svc must have 8hrs EBI. 4 before counted in ratio, rest w/in 90 days.

raw_content: Pre-service Emergency Behavior Intervention training for staff and caregivers is a 6 hour training.

Correction Narrative: The inspector received an email from the Program Director on 11/14/23. EBI training certificates for the caregivers reviewed were sent. An EBI refresher training was provided to caregivers on 11/13/23. The plan moving forward is to provide all 8 hours of pre-service EBI training at once, then do refreshers for annual training. The certificates were added to the document library.


facility_name: The Children's Home

summary: 748.1101(b)(2) - Children's rights-Family contacts: maintaining regular contact with parents and siblings, unless restrictions needed because of child's best interest

raw_content: A child in care was permitted to participate in an unsupervised visit without approval from the caseworker.

Correction Narrative: On January 9, 2026, an e-mail was received from the administrator indicating Amarillo Children's Home house parents will be instructed to document all face to face conversations about visits or family contacts within the youth file so that there is a written record of any permissions given. ACH Case Managers will perform quarterly update reviews of the youth contact list and then submit them to the youth's caseworker to ensure records match.


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

raw_content: A caregiver did not complete annual normalcy training for the current year.

Correction Narrative: On January 9, 2026, an e-mail was received from the administrator indicating the home life coordinator will perform bi-monthly (on the 1st and 15th, or next business day) training checks for any staff who has a training coming due within the next 30 days and alert individual staff to any trainings that need to be completed.


summary: 748.125(d)(4)(D) - Suicide Screening- Must be administered every 90 days after admission for children 10 years of age or older in a GRO that is not a RTC.

raw_content: A suicide screening for a child in care was not completed within 90 days.

Correction Narrative: Operation administrator reports that they have implemented additional systems that coordinate with plans of service dates in order to ensure that suicide screenings are completed according to Minimum Standard requirements.


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

raw_content: A child in care did not received his medication as prescribed on multiple dates.

Correction Narrative: The operation conducted a meeting and reviewed all the expectations of minumum standards when administrating medication including OTC medication. The direct care staff were retrained on how to document medication logs and when serious incident should be reported for a medication error and when to contact pharmacist.  The caregivers were also informed on the expectation regarding the documentation of missed dosages such as who, when and why the medication was missed.


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

raw_content: A child in care did not receive a suicide risk screening at the time of admission

Correction Narrative: The operation understands that at the time of each admission a child must has a risk assessment. The operation spoke with case managers and informed them that if a child is discharged and then re admitted they must has a suicide screen completed.


raw_content: The operation did not complete suicide screenings for a resident every 90 days.

Standard Number / Description: 748.125(d)(4)(D) - Suicide Screening- Must be administered every 90 days after admission for children 10 years of age or older in a GRO that is not a RTC.

Correction Narrative: An email was received from the Director of Programs, which stated that they have added a tab in the online computer software in order to track the required 90 day ASQ suicide screenings.  This will help to give case managers an additional reminder to complete the required screening.


raw_content: Medication prescribed for a child in care was not administered in accordance with the medical instructions provided.

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

Correction Narrative:
On 09/30/2025 an email was received stating a meeting will be held 10/01/2025 where Director of Programs will clarify and remind all direct care staff of the different expectations for administering medications. All direct care staff will also be sent this clarification by email.
ON 10/08/2025 a follow up inspection was conducted. Insp #4079430. Med logs were reviewed with no concerns. An agenda of the meeting was received indicting medication was reviewed. Agenda was also emailed to all direct care staff and supervisors.


summary: 748.125(e)(1)(A) - You must immediately refer a child to a MH professional for a suicide risk assessment if screening finds child to be at a high risk for suicide.

raw_content: A child in care was not referred to a mental health professional after being identified for high risk for suicide.

Correction Narrative:
An email received on 09/30/2025 indicated to ensure suicide screenings accuracy, all screenings will be sent to the Director of Compliance and Treatment Director for final review.
Insp #4079430-Administrator stated protocols will be followed when a completed suicide assessment is high risk. Child will be referred to a mental health professional and will not be left alone.


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

raw_content: A case manager signed a service plan for the caregivers.  Signatures of participants validate their participation in the development and implementation of the service plan.

Correction Narrative: The inspector received an email from the operation administrator stating that all professional-level service providers will be required to take an annual ethics course.


summary: 748.2307(6) - Other Prohibited Punishments-pinching, pulling hair, biting, or shaking a child

raw_content: A caregiver attempted to gain leverage by holding on to a child's hair resulting in the child hair being pulled.

Correction Narrative: A follow up inspection has been completed at the operation.


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

raw_content: The caregiver failed to demonstrate competency, judgement, and self-control when provoking a child to an escalated state when threatening to reset the child's phone to default settings.

Correction Narrative: A follow up inspection has be completed at the operation.


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

raw_content: A caregiver placed his hand over the child's mouth while conducting a short personal restraint.


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: A caregiver failed to use de-escalation skills prior conducting a short personal restraint on a child.


raw_content: 3 of 5 child records suicide screening were not completed on time.

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

Correction Narrative: on 3/31/2025 Operations Executive Director and Director of Intake and Compliance met with Homelife Supervisors/Case Managers and all members of the On-Call team and reviewed the citation for completing suicide screening at the time of admission.  Clarification was provided to all team members regarding the need for a suicide screening to be completed on the same day a youth is admitted to ACH if they are 10 years of age or older.


summary: 748.125(f)(2)(A) - Protocols must include weekly screenings for the first 30 days or until the child is no longer reporting suicidal thoughts, whichever is longer.

raw_content: The operation failed to ensure that weekly screenings were completed following a child being discharged for a behavioral health hospital.  The child was discharged on 1/8/25 and suicide screenings were completed on 1/14/25 and 2/5/25.

Correction Narrative: An email from the operation administrator indicated that ACH Director of Intake and Compliance met with ACH case managers on 3-4-25.  Minimum Standard and ACH policy and procedure were reviewed regarding the requirement for completion of weekly ASQ screenings following a youth's return to campus after being in the behavioral health hospital.  All acknowledge the information reviewed and desire to fully meet this standard consistently moving forward.  Additionally, Director of I and C met individually with the case manager for Thomsen Cottage on 3-4-25 to review the unique challenges that occurred regarding this particular youth and the youth's multiple runaways and shared additional verbal guidance provided by Inspector.


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

raw_content: A child was placed at the operation on 12/26/24 and a preliminary service plan was not completed until 12/31/24.

Correction Narrative: An email was received from operation administrator which indicated that they have provided the following instructions in order to ensure compliance.  ACH Director of Intake and Compliance met with ACH case managers on 3-4-25.  Minimum Standard and ACH policy and procedure were reviewed regarding the completion of the Preliminary Plan of Service within 72 hours of a child's admission to ACH.  All acknowledge the information reviewed and desire to fully meet this standard moving forward.  Director of I & C met individually with the case manager for Thomsen Cottage on 3-4-25 to ensure she understood how the calculation for the 72-hour requirement is done.  Also discussed was the circumstance around the youth's admission the day after Christmas and the impacts of corporate holidays and scheduled personal time off.  Additionally, the Director of I & C met with the Executive Director to acknowledge the unique challenges around the admission and discharge of youth on and around corporate holidays and scheduled personal time off.  Moving forward, the ED and other key leadership staff will ensure that corporate holidays and scheduled personal time off will support compliance with plan of service completion timeframes.


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: two of five childrne were missing the TB test.

Category: Child Care

Correction Narrative: The agency has updated their citation by implementing the agency have children tested with in 30 days of admission. The administrative department will be responsible for reminding cottage parents.


summary: 748.1531(a)(3) - Medical care-A child in care must receive medical care as needed for ongoing maintenance of medical health

raw_content: A child in care did not have his annual medical exam completed in time.

Correction Narrative: The operation has begun weekly internal audits to ensure no appointments are missed. The administrative department will inform foster parents of any upcoming appointments needed.


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

raw_content: A child in care did not have his dental exam completed.


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

raw_content: A child in care made statements of self-harm and the operation failed to appropriately conduct a suicide screening.

Correction Narrative: An email received from the operation administrator stated that the operation has completed annual suicide prevention training on 11/6/2024.  All direct care staff and employees were required to complete the training.  The administrator has reviewed on-call procedures related to suicide prevention, intervention and postvention and reviewed on-call procedures related to the ASQ screening.  Home life supervisors/case manager have reviewed with cottage staff the requirements related to reportable incidents and when they should notify on-call regarding statements of self-harm or suicidal ideation.


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

raw_content: On multiple occasions an overnight caregiver was engaged in other activities that disrupted routine supervision and job duties as the sole caregiver counted in ratio.


summary: 748.949(b)(4) - Annual Training Documentation-Includes the trainer's name and qualifications, or the source of the training for self-instructional training

raw_content: Staff record had a written note as proof of training credentials.

Correction Narrative: The operation has developed a new system which allows them to track all the training needed by contracts and Childcare regulation. The operation understands the importance and what information is needed regarding the trainer's name, course and length of time. They will begin to issue certificates for in house training.


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

raw_content: Caregiver did not complete Normalcy training with in the 12 months of the previous training.


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

raw_content: Cottage toilet was leaking water.

Deficiency Narrative: Cottage toilet was leaking water.


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

raw_content: Two of the two discharge records reviewed did not have the date and circumstances of the discharge.

Correction Narrative:
Email received from the administrator:
 The Director of Intake and Compliance has reviewed this minimum standard and will take appropriate corrective actions to ensure Discharge Summary's (Placement Summary Form 2279)  and all applicable discharge information is completed and sent to the new placement and/or the SFM Permanency Specialist on the resident's date of discharge from ACH. **For the 2 records that were reviewed on 8-23-22, ACH  Executive Director has completed the Discharge Summaries/Form 2279 and they were sent via email to the SFM Permanency Specialists on 9-1-22.


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

raw_content: All medications logs in 4 cottages did not reflect the time medication was given to the child.

Correction Narrative: Email received and copies provided of the medicatiThe ACH administrative team met on 8-24-22 to review the current medication logs and to problem solve a solution for a necessary space for direct care staff to document the time a medication is administered.  It was concluded that ACH would discontinue having residents initial the medication log sheet and utilize this space on the log to record medication administration times. This change was disseminated to all direct care staff and cottages via email on 8-24-22 at 2:41pm.  Additionally, Kristin Elms, Youth Data Coordinator, personally went to each cottage the afternoon of 8-24-22 and reviewed this new on logs with the date and time now being tracked daily.


summary: 748.2151(e) - Medication Record-must document non-prescription medication or supplement given to child and how often given

raw_content: Non prescription medication was not documented in the child's record.

Correction Narrative:
Email received from the administrator on 8/31 all direct care staff were verbal retrained and reminded
 that non prescription medications are to be logged just the same as prescription. All home supervisors and management will continue to monitor to ensure compliance is met.


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

raw_content: 3 out of 4 child admission records reviewed were not completed prior to the child's admission/placement.

Correction Narrative: Email received from Administrator: The Director of Intake and Compliance has reviewed this minimum standard and will take appropriate corrective actions to ensure Admission Assessments are completed prior to a resident's admission to ACH


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

raw_content: Caregivers failed to document a child's refusal to accept medication.

Correction Narrative: Follow up completed on 10.19.22. Operation has completed additional training on how to document child records including medication records. During inspection medical records were reviewed and documentation was completed correctly.


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

raw_content: Staff and caregivers did not update the active record for multiple children.

Correction Narrative: Follow up completed on 10.19.22. Operation has completed additional training on how to document child records including daily notes and medication records.


summary: 748.3475(b)(1) - Safety Requirements-Ensure that hazards or defects identified during the playground inspection are removed or repaired promptly

raw_content: During an afterhours inspection a railroad tie on the playground was split and cracked about 2 1/2 inches.


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

raw_content: During an afterhours inspection one cottage had several expired medications dates were 10/2021, 4/2022,5/2022.


summary: 748.2301(b)(3) - Disciplinary Measures-must be individualized to meet each child's needs

raw_content: Disciplinary action was imposed on an entire cottage.

Correction Narrative: Emailed received from the administrator stating staff have been retrained in disciplinary measures. Training went over how discipline needs to be individualized.


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

raw_content: A caregiver failed to supervise a child in care resulting in the child engaging in inappropriate behavior.

Correction Narrative: Administrator emailed the training that all staff will receive on 1/22/2022 about child's service plan supervision and the operation's levels of supervision.  The two staff involved in the investigation are no longer employed at the operation.


facility_name: Texas NeuroRehab Center

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:
During the course of the investigation, it was observed
the master service plan, the initial nursing treatment plan, and the initial clinical review documents did not contain information regarding self-management of child's  illness .

Correction Narrative: The operation emailed their compliance stating the following: Nurses have been re-trained on the requirement to include all medical problems on the Initial Treatment Plan and Master Treatment Plan. All nurses are expected to read/sign the attestation no later than 3/30/2026 or before working their next shift after this date.


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: It was determined there were only 2 staff present for multiple hours with 18 children. 2 additional staff were present but were providing 1:1 care and unable to be counted in ratio.

Correction Narrative: Interviewed 2 children and 2 staff and the operation had nurses complete a training and acknowledge ratio must remain at all times. The operation is offering shift bonuses and hiring bonuses to help when additional coverage is needed. Children and staff interviewed confirmed they were appropriately supervised and in ratio.


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

raw_content: It was observed 2 out of 2 staff files reviewed did not have the required annual training hours or courses.

Correction Narrative: A training schedule was created to ensure all caregivers receive a minimum of 50 hours of training prior to December 31, 2025. Human Resources will monitor all employee files for compliance in training. Department leaders will be held accountable that their staff have that required amount of training.


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

raw_content: It was observed the unit's showers had mildew on the ceilings and grout, as well as two cockroaches in the shower.

Correction Narrative: During Follow-up inspection the Chaparral unit showers were observed to be clean and free of pests. Operation sent compliance via email on 7-7-25 with pest control and cleaning maintenance. The portion of the peeling ceiling was peeled and painted. New grout was being applied to the showers.


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

raw_content: It was observed 2 out of 2 staff files reviewed did not contain the required 2 hours of Trauma Informed Care training.

Correction Narrative: All employee files were reviewed to identify any employee who has not completed the annual 2 hours of Trauma Informed Care training. All identified employees were assigned training to be completed by August 31, 2025. Human Resources will monitor all employee files for compliance in training.


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

raw_content: It was observed 2 out of 2 staff files reviewed did not contain the required 1 hour of Normalcy training.

Correction Narrative: All employee files were reviewed to identify any employee who has not completed the annual 1 hour of Normalcy training. All identified employees were assigned training to be completed by August 31, 2025. Human Resources will monitor all employee files for compliance in training.


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

raw_content: A child was restrained for attempting to walk out of the cafeteria without permission which does not constitute an emergency situation where the child or others safety was at risk. The child was not on any safety plan or precautions at the time of the restraint.

Correction Narrative: Follow-up inspection was completed. SAMA Training Documentation was observed and compliant. 2 staff and 2 children were interviewed and confirmed EBI are used only in emergencies and conducted appropriately.


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

raw_content: A child was inappropriately restrained by a staff member who placed their arm around the child's neck.

Correction Narrative:
The operation provided the following compliance on 6/27/25 by email:
The employee was required to be retrained in Satori Alternatives to Manage Aggression (SAMA).  The SAMA course addresses appropriate techniques when placing patients in a physical hold.  The SAMA instructor targeted containment techniques and personal-defense release.  The training was conducted on 6/25/25.  The employee demonstrated competency. The Director of Nursing will monitor for any complaints of inappropriate physical hold technique by this employee.

A follow-up and unannounced inspection were conducted on 7-1-25. The 4-hour SAMA Training documentation completed by staff was observed and compliant. 2 children and 2 staff interviews were conducted regarding restraints. There were no concerns.


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

raw_content: It was determined staff were out of ratio when a physical altercation occurred between children in care. 2 children, 3 staff, and parent stated the ratio was 2:15 when the incident occurred.

Correction Narrative: Follow-up inspection was completed. Ratio was observed and compliant. 2 Staff were interviewed and confirmed the unit is in ratio at all times.


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

raw_content: During the investigation, a staff member reported that they used a threat of a personal restraint as tool for disciplining the child.

Correction Narrative:
The Director retrained the staff member through power point presentations that address appropriate management of behaviors and therapeutic communications. An assessment of staff members comprehension of materials was completed during the meeting. 1/29/25- DJ

RCCR Inspector conducted a follow-up inspection regarding citation. A review of the PowerPoint training was conducted, as well as 2 children and 2 staff interviews. Staff interview, who allegedly threatened use of EBI as discipline or punishment. It was stated he understood the training and explained his comment was to notify the child who was trying to engage in a physical altercation with another child, it would result in a code call and the use of an EBI. It is recommended Administrative Review consider citation, as the mention of EBI was not a threat of punishment or discipline. 2 children engaging in a physical altercation is considered an emergency and poses risk of harm to children. Staff statement was to explain clear outcomes if children continued in trying to fight physically. A walkthrough of the Chaparral and Sierra units were conducted. There were no concerns. 02/07/25 JB


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

raw_content: It was found that sections [748.311(2), (4), (5), (7), and (8)] of the incident report documentation were missing required information.

Correction Narrative: A training was reviewed for 3 nurses who took the serious incident report and injury training. No interviews were completed with the nurses as they were unavailable at the time of the inspection. 4 SIRs were reviewed and reported timely with all required information.


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

raw_content: It was found that the incident occurred on 11/5/24 and staff were aware of the childs right-hand injury on this day, however the incident wasnt reported to the A/N Hotline until 11/8/24.


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

raw_content: During the course of the investigation, a staff member and a child reported that the child was restrained briefly on their back (in a supine position).

Correction Narrative: Two staff and six children were questioned about how restraints are performed at the operation. No concerns were noted.


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

raw_content: Several people interviewed reported a staff member used profane language following a personal restraint in front of a children in care.

Correction Narrative: An email was received from the operation on 11.1.24. The operation had the staff member involved sign an attestation regarding the incident. The attestation can be found in the document library.


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: Instead of permitting other staff to manage and defuse the situation, a staff member exacerbated the situation by intervening even though they were aware the child was upset with them.

Correction Narrative: During an in-person inspection, interviews with 4 residents confirmed that staff are making all attempts to verbally descalate a situation and using restraints as a last resort. Intereviews with staff confirmed that all direct care staff received Trauma Informed Care training addressing triggering behaviors.


summary: 748.2461(a)(2) - Short Personal Restraint-Caregiver must use minimal amount of reasonable and necessary physical force

raw_content: A child received a bloody, swollen nose during a restraint due to a staff member banging their head on the ground.

Correction Narrative: During an in-person inspection, interviews with 4 residents confirmed that staff are making all attempts to verbally descalate a situation and using restraints as a last resort. Residents interviewed reported that they have never been injured during a restraint. Staff interviewed confirmed that the new restraint training includes the topic of using the minimal amount of force during a restraint.


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

raw_content: While a child was being restrained by staff, another staff choked the child.

Correction Narrative: During an in-person inspection, interviews with 4 residents confirmed that staff are making all attempts to verbally descalate a situation and using restraints as a last resort. Residents reported that they have not witnessed an inapprorpriate hold. Staff confirmed that a refresher EBI training was conducted.


summary: 748.2307(14) - Other Prohibited Punishments-withholding food that meets the child's nutritional requirements

raw_content: A staff threw away a child's food in response to the child spitting at their feet.

Correction Narrative: During an in-person inspection, interviews with 4 residents confirmed that staff have not used any forms of inappropriate discipline.