summary: 748.705(b)(3) - Reasonable & prudent parent standard-must consider the child's behavioral history and ability to safely participate in proposed activity

raw_content: A staff member provided razors to children in care with a history of self-harm. Although using razors for shaving is a part of normalcy for teenage children, it seems the staff did not ensure the razors were taken back from the children.

Correction Narrative:
Inspector received an email from the Administrator on 3/16/23: The responsible staff is no longer with the agency.
Future training will continue to focus on normalcy, but with a focus on safety plans and expectations regarding plans. Staff will continue to have the authority to provide razors for kids at AGH, but will also be more responsive in showing the responsibility of taking up razors following use. Training for new employees will consist of a minimum of 4 weeks to ensure more of a focus in the milieu and expectations regarding prudent judgement through New Horizons Policy, Philosophy and contract minimum standards are followed. Staff will continue to receive Normalcy training annually as well as a throughout the year through various trainings of the program, including, but not limited to activities, off campus and on campus trips, knowing your kids, and the most recent suicide prevention, intervention, and postvention policy.
Please accept this as AGH response to ensure the safety of all children in our care.
The inspector also spoke to the administrator on the phone on 3/16/23 to discuss follow up and admin review status. Michelle said they did request admin review. JG


state: TX

facility_name: New Horizons Audrey Grace House RTC

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

raw_content: A staff member admitted to cursing at a child during an interaction with the child. Witnesses, including staff and children, corroborated this incident.

Category: Individual Standards Evaluated

Standard Risk Level: Medium High

Corrected at Inspection: No

Correction Narrative:
Inspector received the following email from the Administrator on 3/3/23:
Staff Tatiana met with Administrator regarding the incident. Immediately following the incident Tatiana and John met and apologized which is part of New Horizons Philosophy to fix things with the other person. Tatiana is aware with the incident and her actions could and should have been different. She will continue to work through the New Horizons Philosophy by attending trainings on 3.8.2023 regarding Willing to Learn, Willing to do for every child, Know Yourself, Staff with Heart. Tatiana will attend TBRI in the Spring/Summer of 2023 as refreshers to Connecting, Empowering, and Correcting.
Please accept this as AGH response to ensure the safety of all children in our care.


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

raw_content: A staff member admitted to yelling at a child during their interview. Other staff members, who were 50 yards away, then responded after hearing the yelling.


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

raw_content: A child did not receive a medication due to arrest and runaway. Documentation for the missed dosages were not noted on the medication log/medication error.

Correction Narrative:
Inspector received the following email from the administrator: "All staff have completed in person psychotropic medication training with a Registered Nurse on 1/11/2023. A Medication Administration Training has been set up beginning 2/9/2023, 2/16/2023, and 2/23/2023. Staff are attend one of the 3 trainings conducted by the Registered Nurse that includes documentation, review of medication, ensuring children are taking medication." The inspector was on campus on 2/9/23 and observed some of the training that was being provided to multiple staff by the nurse on campus. The nurse was discussing administering medication to children in care.
As well, "Since January 1, 2023 the nurse is inputting all medication errors in K-care under Medication Error Report and staff are completing incident reports of any medication errors, including refusals. New Hire training will include medication administration training as well." JG


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

raw_content: A child was held in a supine hold for about 28 minutes, as stated in the incident report. It is noted that staff involved stated they gave the child opportunities to transition out of the hold but the child was fighting back.

Standard Risk Level: High

Correction Narrative: Inspector received the following email from the administrator on 1/25/23: Staff have been notified that the use of supine hold is not an approved restraint technique and that the child must be released, and the restraint is restarted to avoid any supine holds. AGH is continuing to focus on the use of de-escalation skills to be the primary when working with kids instead of physical hold. JG


summary: 748.2855(c) - EBI Documentation-If personal restraint, must include specific restraint techniques used, including prone/supine restraint used as transitional hold

raw_content: The incident report did not state the specific restraint that was used. It states "held on the ground as safely as possible," which references a supine hold. Several staff involved were interviewed to confirm the child was in a supine hold.

Standard Risk Level: Medium

Correction Narrative: Inspector received the following email from the administrator on 1/25/23: Staff are continuing to being worked with on accurate documentation and to be specific in their reports. Staff received training/discussion beginning 1.17.2023. Administrator, Team Leads, House Director, and Therapists will continue to review incident reports for accuracy and details. JG


raw_content: 3 children and one staff all consistently described another staff calling a child an elephant, referring to their weight.

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

Correction Narrative: Inspector Jordan Green received an email from the administrator on 1/25/23: The specific staff was written up on 1.23.2023 when she returned to work. Staff are required to and will continue to attend trainings that focus on philosophy and the use of TBRI where relationships and nurturing are the focus. JG


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

Correction Narrative:
On 12/14/2022 received an email from Michelle Perkins, Administrator regarding the response to deficiency given on 12/02/2022 regarding a child allegedly sneaking out and staff not being aware of the absence MS 748.685(a)(3) Caregiver responsibility - being aware of and accountable for each child's on-going activity
Reported Deficiency A child eloped at night from the operation and staff was not aware that the child was gone.
Provider Response: Staff was visited with on 12/02/2022 regarding documentation and supervision measures. Staff will complete a specific training on Supervision the week of December 12/12/2022. Documentation will be a primary focus on ensuring things are accurately documented and staff are hypervigilant about kids whereabouts. Window and door alarms have been installed to provide added supervision as well.
Please accept this as AGH response to ensure the safety of all children in our care.


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

raw_content: Several children mixed and drank almond and mint extracts during lunch at the operation. Staff were present during lunch, however the children were still able to obtain and ingest these mixtures without staff noticing. As a direct result, one child who drank the mixture later had an allergic reaction that required medical treatment.

Correction Narrative: The following response was received from the Administrator: Staff responded quickly and professionally to the situation. Staff will continue to focus on accurate supervision. AGH had a staff meeting on 9/14/2022 where supervision was addressed as the focus of the meeting. Supervisors continue to address supervision with staff and the importance of it daily.


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

raw_content: During a walk through cleaning supplies were observed under a the bathroom's cabinet.

Correction Narrative: Received compliance response from the administrator Michelle P., via email. It was stated that staff was made aware of the unlocked cleaning chemicals at the time of walk through. Locks were placed on the cabinet under the sink and staff were reminded to keep cleaning chemicals locked up from all children unless in use to ensure the safety of all children in their case.


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

raw_content: There was conflicting information in the serious incident report including referring to a prone restraint instead of a supine restraint. Also, the times of the total restraint were inaccurate and information about a staff being present when the staff had stepped out of the room during the incident.

Correction Narrative: The following was received from the Administrator: AGH staff were made aware on 9.21.2022 to document restraints in their words rather than using specific words such as prone/supine. Staff will continue to use the restraint report and fill in accurate information related to restraints and incidents. Incident reports are reviewed by clinical staff to ensure accuracy and documentation consistency.


summary: 748.2801(2)(B) - EBI Time Limits-Prone or supine personal restraint hold may not exceed one minute.

raw_content: It was found that a child in care was in a prone restraint for longer than 1 minute.

Correction Narrative: The following response was received from the Administrator: An administrative review has been requested on this investigation. In the mean time AGH will continue to focus on getting kids in a basket hold and transitioning to a basket hold as soon as they can. If a restraint is required staff will sure the child's limbs and airway are free from any obstruction to cause injury while holding the child as safe as possible and working to transition to basket hold with cooperation of the child.


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

raw_content: During the course of the investigation it was determined that staff failed to confirm address and coordinate with relative that resulted in child in care being dropped off in unapproved location.  Staff also failed to provide medication to adult relative which resulted in child gaining direct access to the medication.

Correction Narrative: Agency administrator provided written follow up stating staff complete Normalcy training at new hire and again Annually for training. The agency Philosophy covers Trust and Verify which means that we trust kids, co-workers, and staff, but we also verify and follow up. Both trainings and philosophy are a core focus for all staff throughout employment and will continue to be so. This particular staff involved in this specific incident was spoken to by leadership staff at AGH and understands the expectations to avoid similar incidents in the future.


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

raw_content: There were two documented instances in the same month of medication records showing that a dose of medication was missing from the containers.

Correction Narrative:
On 6/1/2022 the operation sent the following plan of compliance: investigate. Since January, documentation of medication errors has improved at Audrey Grace House (AGH) with a registered nurse being the primary individual overseeing medications. She checks boxes 3 times weekly and staff check the on additional days to ensure administration, staff signing out medications, and corrected counts of each medication. When errors are noticed they are reported and documented. This will continue to be the plan moving forward with additional changes as necessary.

This is being accepted as it was previously turned into contracts prior to this investigation as compliance and due to marked improvement of medication records reviewed during this investigation since the nurse took over duties.


raw_content: There were discrepancies on the medication count on three medication logs that were reviewed. No documentation of the purpose of remaining medication for each medication.

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

Correction Narrative:
RCCR Inspector Sandra Melgar received an email from Michelle Perkins, Administrator at New Horizons AGH and her response to this minimum standard was as follow:

748.2151(d)- Medication Record- must include accurate daily count of each prescribed medication, unless operate as a cottage home model.
Provider Response:- AGH Nurse checks medication boxes at a minimum 2x per week in an effort to ensure correct counts.  Each medication is designated it's own form and printed to ensure legibility and accuracy.  In the notes section of each log it is documented if a medication is dropped, missing, disposed of as well as, but not limited to when the child goes on a visit and medications are taken with as well as any medications taken to school for administering.  Logs are verified with medication packs to account for each medication.


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

raw_content: Missing dosages were not administered or partial dosages were administered according to the medication logs for more than one medication.

Correction Narrative:
RCCR Inspector Sandra Melgar received an email from Michelle Perkins, Administrator at New Horizons AGH in response the deficiency for this minimum standard:

748.2003(b)(5)- Administration of prescription medication- Ensure the child has taken the medication as prescribed.
Provider Response- In accordance of 748.2151 above, AGH has updated the medication logs to print directions of each medication and proper administration.  Staff will continue to receive new hire, annual, and ongoing training on medication administration along with documentation.  Staff will ensure the 5 Rights are followed when administering medications Right Person, Right Medication, Right Dose, Right Time, and Right Route.


raw_content: While reviewing the medication logs for Clonidine 0.1mg, Concerta 36mg, Focalin (Dexmethylphenidate) 10mg and Focalin 40mg it was found that there were no medication error reports for missing dosages.

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

Correction Narrative:
RCCR Inspector Sandra Melgar received an email from Michelle Perkins, Administrator at New Horizons AGH. Michelle sent the following response for this minimum standard:

748.2203(c)- Medication Error- Operation must meet documentation requirements within 24 hours of notice of the error.
Provider Response- At the time of this report it was not reported to the RN that medication errors were to be documented any where other than on the medication log.  However, since July 2021 all medication errors are documented on the medication log as well as in the system Kaliedacare under Medication Error Report.  This is documented by the RN at AGH when noticing the error or becoming aware of the error by staff administering the medication.  This report reflects time and date of error, medication name, issues surrounding the error, doctors recommendations of the error, if necessary.  Not all errors require a doctor notification such as a skipped dose per Dr. Siddiqui requires continue with the next dosage as recommended, but do not duplicate.


raw_content: If staff was properly supervising child while vacuuming van, child would not have gained access to first aid kit and ingest excessive medication requiring medical attention.

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

Correction Narrative: The operation has bought and is utilizing a lock box with a padlock to store the first aid kits and fire extinguishers for the vehicles they use for transportation. Pictures of the lock box with the items in them are uploaded to digital storage.


summary: 748.303(a)(8)(A) - Serious Incident-Report to CCL within 2 hours of notifying law enforcement unauthorized absence of a child developmentally/chronologically 6 to 12 yrs

raw_content: An unauthorized absence of a child between 6-12 years of chronological age was not reported to CCR until 5 hours and 42 minutes after the unauthorized absence was discovered and reported to the police

Correction Narrative: The operation sent this inspector a guide given to all staff and case managers through a memo that details the timeframes for reporting serious incidents regarding law enforcement and unauthorized absences. This was gone over in a training with staff as well and is reviewed with staff by the program director during any serious incidents


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

raw_content: One of the two children in care were not debriefed upon their return to the operation

Correction Narrative: On 7/20/2021, this inspector reviewed an updated form for unauthorized absences that has a template that better prompts the writer to fill in the debriefing portions with everything that is required in minimum standards.


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

raw_content: There was no time or date documented on either of the SIRs of when the parents and LE were notified of the UA. Neither parents of the two children were mentioned.

Correction Narrative: SIR was modified to include prompts for all required information.


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

raw_content: A child's service plan did not detail a history of self-harming though it was reported by staff and used as a basis for emergency behavior intervention and restraints

Correction Narrative: On 5/14/2021 I, RCCR Inspector Brody Ratto, received a memo from Audrey Grace House sent to it's clinical staff containing instructions to ensure that high risk behaviors are documented in the child's service plan. This is signed by all the clinical staff. The child in care whose service plan was deficient is no longer in their care so an updated service plan for them would not have been appropriate.


summary: 748.2605(b)(1) - Personal Restraints Prohibited-Prone and supine restraints except as a transitional hold that lasts no longer than 1 minute

raw_content: A review of 19 restraints showed 7 prone and supine restraints performed on one child. Additional children and staff reported that supine restraints were utilized often.


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

raw_content: Out of 19 restraint reports reviewed, 4 restraints were performed to prevent a child from running away from the operation when there were no other dangers present to the child.


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

raw_content: There were not specific plans on how the child in care would be supervised. Such as whether eyesight and/or hearing range would be used or how often visual checks would be conducted. The plan stated due the child's history, the child will need close supervision.

Correction Narrative: It was discussed in staff meeting on 5.12.21 and leadership meeting that service plans should be individualized and current to each child, should be updated as needed, and that content can be reviewed as necessary.


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

raw_content: The service plan was not followed in regards to supervision. The child's plan stated when the child becomes upset or attempts to withdraw, staff members will close the distance between them in order to provide better supervision and increase safety.

Standard Risk Level: Medium Low


facility_name: Bridge the Gap Foundation

summary: 748.3235 - Evacuation-Must post the emergency evacuation & relocation diagram in a prominent/visible location in all buildings

raw_content: There are no evacuation diagrams in all the buildings.

Category: Safety and Emergency Practices


summary: 748.3601(4) - Swimming Pool-Pool chemicals & pumps must be inaccessible to children

raw_content: Swimming pool pump is accessible to children in care.

Category: Physical Site


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

raw_content: The reason for one medication was not documented on the medication log reviewed.

Correction Narrative:
In-person follow-up was conducted.  All medication logs were reviewed and found in compliance.  Admin stated the child was brought into care with the medication and the reason for the medication was not listed.  Admin stated it was just the one medication that didn't have a reason.

Email received from Admin: Immediately upon identification of the deficiency, the medication log was reviewed and the prescribing information was verified through the child's medical documentation.  The reason for the medication was added to the mediation record to ensure the record is accurately reflects the prescribing purpose.
The administrator also reviewed all current medication logs to ensure that each prescription medication listed included the reason it was prescribed.

Preventative Measures: staff received refresher training, staff will be required to verify and document the medication name, dosage, route, time administered, reason prescribed, and any side effects.  Direct care staff will review logs during shift and administrator will conduct monthly audits of records.


raw_content: The child's initial service plan did not address high risk behaviors.

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

Correction Narrative: An email was sent from the administrator regarding a child initial service plan did not address high risk behavior. The administrator stated that within 24 hours of admission, staff will conduct an initial risk screening to assess: history of self-harm or suicidal ideation. The documents can be found in the document library.


summary: 748.4001(b) - General requirements-must ensure the safety of all children during any transportation that the operation provides

raw_content: A staff member put a vehicle in drive and stopped the vehicle while a child attempted to get into the vehicle, resulting in a child receiving an injury.


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

raw_content: The operation did not report the first quarter EBI data timely.

Correction Narrative: RCCR Inspector spoke with the operation about compliance. Staff will create calendar reminders and will assign multiple workers to the reminders to ensure data gets submitted timely. Compliance has been met for this standard.


raw_content: A child's service plan did not document detailed information telling a caregiver how to observe and keep watch over a child in care.

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

Correction Narrative:
The operation asked for more time to come into compliance. Extension was approved by RCCR Supervisor and new compliance date was changed to April 26, 2024.

The operation hosted a training for their caregivers on April 30, 2024. The training went over child plan documentation instructions for the level of supervision needed for each child in care. The sign-in sheet was reviewed to confirm the participation of staff. The operation assigned a staff member to ensure each caregiver understands the supervision plan for each child.


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

raw_content: The operation's fire iinspection has expired on 08/10/23.

Correction Narrative: An email was received from the Administrator indicating that they have created a check list of all annual inspections to ensure they are not missed.  A copy of the check list was received.  The fire inspection was completed on 08/28/23.  A copy of the inspection was received.


summary: 748.1531(b)(1) - Medical Care-Written record of each medical examination must include a copy of the results

raw_content: Two files that were reviewed did not have the dental results documented.

Category: Child Care

Correction Narrative: An email was received by the Administrator indicating that they have put in place a new procedure regarding ensuring all medical and dental documentation has the results of the visit.  She will be the final staff to review all documentations before they are filed in the file.


summary: 748.4213(c) - Emergency Care Discharge Plan-must obtain documentation from person responsible for child that preliminary discharge plan is reviewed/updated weekly

raw_content: There were no documentations regarding weekly preliminary discharge planning reviews.

Standard Risk Level: Low

Correction Narrative: An email was received from the Administrator stating that they have created a form for the placing agency to fill out regarding the discharge planning review.  A copy of the form was received.  They will be requesting weekly updates.


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

raw_content: There was medication in the refrigerator that was not locked up.

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


raw_content: The child's service plan did not give a comprehensive description, of what the supervision should entail.

Correction Narrative: RCCR Inspector received an email from the Administrator.  It indicates that the Administrator will ensure that all service plans have a thorough details regarding the children's supervision needs.  The service plan will highlight in detail what specific issues the children are dealing with and how to address it and the timeframe.  A copy of the updated service plan was received.  A safety plan was also attached regarding supervision for one of the children in care.  This was to address the supervision plan for the child and children are safe.


summary: 748.4211(a) - Placement Extension-Must document reason for continuing emergency care services in child's record by 16th day that child is in care

raw_content: The operation was not completing the place extension documentation by the timeframe required.

Correction Narrative:
An email was received from the operation with copies of the 16 days monthly notes.  They stated that this is their placement extension.  They did send a copy of what they place in the child's file. An inspection will be conducted on 12/06/22 to review all children's files who have been there more than 15 days for the placement extension.
An inspection was completed on 12/06/22 and confirmed that the extension documentation was completed for the children that have been at the operation more than 15 days.


raw_content: The level of supervision was not listed on two service plans that were reviewed.

Correction Narrative: An email was received from the Administrator stating that all service plans will be reviewed in detail by the Administrator regarding all areas, especially supervision.  This will include supervision inside and outside of the home for the children in care.  A training was provided on 12/15/22 and the sign in sheet was received.


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

raw_content:
There were three serious incident reports that were not completed.

748.311(4) 2 out of 3 did not have the adults that were involved.
748.311(8) 2 out of 3 did not have follow up interventions.
448.311(9) 3 out of 3 did not have the threating health care provider.

Category: Reports and Record Keeping

Corrected at Inspection: Yes


summary: 748.3601(6) - Swimming Pool-all parts of the swimming pool must be clearly visible during use of the pool

raw_content: On the day of the outing the water to the swimming pool was not clear.

Correction Narrative: The operation sent an email stating that Bridge The gap will ensure that going forward the girls will  use a public pool with city regulations, if staff notices issues with the water, or the pool not being clear they will immediately vacate the premises. The staff were trained on 06/22/22.


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: Two medications were not given as prescribed to a child.


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

raw_content: On 1/13/22, there was not a signature or initials of who administered the medication to one child.

Category: Medication

Correction Narrative: An email was received from the Administrator stating that all staff completed a training on 02/01/22 regarding medication documentation.  A copy of the sign in sheet was received.  In addition, the Administrator will conduct daily audits to ensure all medication logs are completed correctly.  They will complete a medication log error form when needed.


summary: 748.981(a)(1) - First-aid-CPR training-Each caregiver must have current certification in first-aid

raw_content:
There was one caregiver that did not have a current first aid training.

The caregiver did complete the training during the inspection.

Category: Training and Professional Development


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

raw_content: The Health Inspection expired on 12/4/21.

Correction Narrative: On 1/21/22, the Owner's stated that they have contacted the inspector and trying to get an inspection scheduled. On 1/25/22, the Owner's stated they have an inspection scheduled for 1/27/22.  Inspector did receive an updated inspection and it was approved. The operation stated they will ensure that they put a check list in place for annual inspections that are due.


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

raw_content: The agency had not validated their background list since they were issued a permit.


raw_content: There were two children's medication logs that were reviewed and it did not have who administered the medication for dates 9/24/21, 9/25/21 and 9/27/21.

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

Correction Narrative: This standard was evaluated and in compliance.


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

raw_content: There were several medical logs that were reviewed that did not have the date and time the medication was given.


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

raw_content: The discharge summary did not have the frequency of the three medications that the child was taking.

Category: Admission, Service Planning, Discharge

Correction Narrative: The standard was evaluated and in compliance.


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

raw_content: One out of two files that were read did not have a signature on the Child Rights indicating that they received a copy of the rights or that it was discussed with them.

Category: Children's Rights


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

raw_content: Two out of two files that were read did not have known allergies listed on the exterior of the child's record.


raw_content: Several children was not given their medication as prescribed by their doctor.

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


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

raw_content: The discharge summary did not have the address or phone number to whom the child was being discharged to.


summary: 748.363(1) - Personnel records-Include date of employment

raw_content: A staff file that was reviewed did not have the following items: 748.363(1) date of employment, 748.363(3) job description, 748.363(6) a notarized affidavit, and 748.363(9) proof of background eligibility.


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

raw_content: One child did not have record of TB testing.

Correction Narrative: An email was received stating that the child that needed a TB has an appointment scheduled for 8/17/21. Due to the child having COVID, this is the earliest it can be completed.  The CPS worker was contacted, and she had no documentation that the child received one in the past.  The operation stated they will ensure when a child is placed, they will ensure they request a copy of the TB.


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

raw_content: One child's medication log did not have the prescribing physician noted.  In addition standard 748.2151(c)(4) was reviewed and the strength of the medication was not documented.

Correction Narrative:
An email was received from the owners stating they will ensure the medication has properly been administered, BTG will execute the following steps effective immediately:
1.) The prescribing health-care professional's name from discharging facility, will be included on the medication log upon admission.
2.) BTG will record the medication strength on medication log upon admission from discharging facility.
3.) BTG will ensure all steps are complete upon admission by using a checklist to prevent incomplete documentation.
4.) Program managers will conduct an admission audit within 72 of admission to ensure all forms are completed in the child file.


summary: 748.191(1) - Required Postings-Post the permit in a prominent and publicly accessible place where others may easily view it at all times

raw_content: The agency did not have the permit posted.


facility_name: DePelchin Children's Center Campus at Today's Harbor

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

raw_content: Sharp utensils and cooking objects were located in the kitchen drawers.


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

raw_content: A large bag of rice was observed open and stored on the floor in the kitchen pantry.


summary: 748.683(2) - Caregiver Supervision-Provide oversight of caregivers to ensure that assigned duties are performed adequately

raw_content: Employee stated they were unaware of the overnight supervision policies.

Correction Narrative:
Corrections submitted via email 2/6/26;
An internal investigation was conducted that proved that the employee chose to ignore the policy that was set in place. When this was discovered, the employee was terminated for not following company policy.To Prevent Future Occurrence:
After this incident happened, all house manager were instructed to remind their staff that residents are not allowed unsupervised in each others rooms. During every monthly staff meeting, the program manager reminds all the staff that the residents are not allowed in each others room unsupervised.


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

raw_content: Caregiver failed to provide adequate supervision resulting in two children engaging in sexual behaviors.

Correction Narrative:
Corrections submitted via email 2/6/26:
Action Plan: When this incident occurred, employee was suspended, and licensing was notified. An internal investigation was conducted, and the employee was terminated a week after this incident occurred.
To Prevent Future Occurrence: Shortly after this incident occurred, an all employee meeting was held, reminding the staff about the rules connected with supervision, and the importance of following them. Every month, a staff meeting occurs, where all the staff are reminded of these rules. The night shift supervisor increased the level of supervision of night-time staff to prevent this incident from occurring again.


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

raw_content: During the inspection, the bathrooms were visibily dirty with items on the counter and floor, as well as trash and hair visibily sitting out and not thrown away.

Correction Narrative:
Action Plan:
After the inspection, all the bathrooms were cleaned.

To Prevent Future Occurrence:
1.After the youth get ready in the bathroom in the mornings, we will inspect all bathrooms for cleanliness.

2.In the evening, once the youth are done with their hygiene routine, we will also inspect all bathrooms for cleanliness.

3.We will also do a mid-day check for bathroom cleanliness as well.


summary: 748.3445(a) - Food Preparation-Food and drinks must be of safe quality, stored, prepared, and served under sanitary & safe conditions

raw_content: During the inspection, all three of the homes where the children reside contained opened bags and opened cans of food in the fridge, pantry, and freezer.

Correction Narrative:
Action Plan:
After the inspection, all the food items were properly stored/discarded based on the TA given by the inspector.

To Prevent Future Occurrence:
1. After meal times, staff will do refrigerator/ freezer/pantry checks to ensure that the food is stored correctly.

2.Night shift will also check the refrigerator/freezer/pantry to ensure that the food is stored correctly


summary: 748.2003(b)(10) - Administration of prescription medication-must not borrow or administer prescription medication to a child that is prescribed to another person

raw_content: A child in care was administered medication that was prescribed to another child.

Correction Narrative:
Action Plan: When this occurred, a medication error report was immediately completed, a licensed medical professional was notified, and the directives of the licensed medical professional were followed.
To Prevent Future Occurrence:
1.
Right after this happened, staff were informed that only pre-approved staff members were allowed to give out medication.
2.
This specific staff is NOT on the list of the pre-approved staff allowed to give medication.
3.
Staff were also informed that when a staff member pulls the medication, they need to be the one to administer it. If they are not able to administer it right away due to behaviors of others, they need to put the medication back in med box.
4.
A few days later, an all-staff meeting was held that covered this topic and how to prevent it in the future. All staff were required to attend.
An in-person follow up was conducted on 08/12/25. Inspector reviewed medication logs and medication packets, and interviewed the victim regarding any additional medication errors; there were no concerns.


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

raw_content: A psychotropic medication was administered to a child in care by an employee who has not taken or completed the required medication administration training.

Correction Narrative:
Action Plan: The staff member who administered the medication was told that they were not allowed to administer medication due to them not completing the training.
To Prevent Future Occurrence:
1.
A few days after this incident occurred, an all-staff meeting was held that covered this topic, and how to prevent it in the future. All staff were required to attend.
2.
This specific staff member will work on finishing their medication training before the date it is due.
An in-person follow up was conducted on 08/12/25. Inspector reviewed medication logs and medication packets, and interviewed the victim regarding any additional medication errors; there were no concerns.


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

raw_content: Child was left unattended.

Deficiency Narrative: Child was left unattended.

Correction Narrative:
Action Plan: Program Manager spoke with staff on 4/8/2025 and sent an email communication to all staff reiterating youth monitoring requirements, expectations, and following internal protocols as well as youth restrictions. Program Manager also conducted a meeting with all staff on 4/2/25 to discuss concerns regarding youth and maintaining consistency in internal practices specific to caregiver responsibility. Additional Counseling & Guidance was provided during in-service on 3/25/25 regarding supervision and staff accountability. All staff will receive training at the next All Staff Meeting on 5/14/25 regarding minimum standards specific to caregiver responsibility.

To Prevent Future Occurrences: Program Manager will continue to provide minimum standards review during onboarding and monthly meetings. The program will continue to have monthly meetings for staff development and implementation of practices and protocols.


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

raw_content: Staff member uses profane language around children in care.

Correction Narrative:
An unannounced inspection of the operation was completed.  Two staff as well as the administrator reported that they have monthly staff meetings in which they discuss appropriate behavior in front of the residents as well as steps to take when the resident's behaviors escalate.  Staff involved in the incident is no longer employed at the operation.

Email received from operation:
Action Plan: Program Manager sent an email communication to all staff on 4/7/25 regarding. Additional Counseling & Guidance will be provided during in-service on 4/16/25. Employee, BR has been terminated due to poor job performance.
To Prevent Future Occurrences: Program Manager will continue to provide minimum standards review during onboarding and monthly meetings.


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

raw_content: Caregiver does not have out-of-stated background check completed.

Correction Narrative:
The administrator reported that they have added an additional procedure with HR to ensure that all appropriate background checks are being completed prior to the caregiver/s beginning employment at the operation.

Email received from operation:
The out of state background checked was inadvertently missed during the pre-onboarding process for an employee. The Human Resources Director was notified. The Human Resource Department will continue to complete all required background checks and confirm clearance prior to the start of the employee. This employee is no longer with the agency as of 4/4/25. Therefore, no further action is needed for the background.
To Prevent Future Occurrences: Program Administrator will confirm with Human Resources that all background checks are completed
before the employee's start date.


raw_content: A Child in care was able to leave the cottage without staff knowing his whereabouts.

Correction Narrative:
Program Manager spoke with staff on 4/8/25 and sent an e-mail communication to all staff reiterating youth monitoring requirements, expectations, and following internal protocols as well as youth restrictions. Program Manager also conducted a meeting on 4/2/25 with all staff to discuss concerns regarding youth and consistency in internal practices specific to caregiver responsibility.

Additional counseling and guidance were provided on 3/25/25 regarding supervision staff accountability. All staff will receive training at all next staff meeting on 5/14/25 regarding minimum standards specific to childcare giver responsibilities. Employee BR has been terminated due to poor job performance.

To prevent further occurrence Program manager will continue to provide minimum standards review during onboarding and monthly meeting for staff development and implementation of practices and protocol.

4/24/25 RCCL Inspector was provided with a copy of the corrective action plan, March 25th agenda, March 25th sign in sheet, Brandon R. termination letter, Brandon R. recommendation letter for termination, April 2 agenda, April 2 sign in sheet, and April 8 commination e0-mail to staff. All documents were uploaded into the library.


summary: 748.2151(c)(8) - Medication record-must include reasons for administering psychotropic medication or non-prescription medication/supplement for a child under 5 years

raw_content: I was observed that the dosage was not provided on the medication logs to ensure child was administered the prescribed dosage per physician.

Correction Narrative: The operation provided a screenshot of the medication log which identifies the reason for the medication. It is embedded on the line with the dosage and strength (it reads as 1xday/ 2mg/ Depression  for Sertraline).


summary: 748.1217(b)(7) - Admission Assessment-must include current mental health & substance abuse status, including available results of evaluations or assessments

raw_content: During a review of records it was observed that a child in care had mental health diagnosis missing from their admission assessment.

Correction Narrative: Admission Assessment was modified on 1/9/2024 to meet TDFPS and YFT standards. Admission Assessment for youth reviewed (KF) was revised on 1/5/24 and 1/9/24 to include assessments of mental health/psychological, substance abuse, etc. as well as results of evaluations.


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: During a review of child files it was observed that a child in care did not a screening tool administered at the time of admission.

Correction Narrative: Suicide Screening tool presented.


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

Deficiency Narrative: I was observed that the dosage was not provided on the medication logs to ensure child was administered the prescribed dosage per physician.


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

raw_content: The child went AWOL and staff failed to conduct a debriefing with the child when they returned to the facility.

Correction Narrative:
Debriefings are always conducted with youth following AWOL and any incidents. Staff failed to document debriefing of AWOL following the youth's return.

To prevent future occurrences, a debriefing protocol and form for documenting debriefings has been created and implemented. All staff were notified of the protocol and debriefing form on 1/5/24. Debriefing was also discussed with all staff at team's All Staff Meeting on 1/10/24.


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

raw_content: During a review of the records, it was observed that a child in care did not meet with a PLSP within 24 hours of being released from the hospital after the child returned to the home.

Correction Narrative: Kelis F. returned to the home on 11/08/2023 and PLSP has been met.


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

raw_content: During a review of the records and interview of staff it was determined that the child care administrator does not maintain full time hours.

Correction Narrative: Operation has identified an LCCA however the system will not allow entering the new LCCA due to a pending data correction.


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 a review of records it was determined that a child in care did not have a list of medications recorded in their preliminary service plan.

Correction Narrative: The operation provided an updated preliminary service plan that included the list medications. The operation will ensure all medications are listed in the preliminary plans moving forward.


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

raw_content: During observation of the first aid kit, the thermometer was missing.  Corrected at inspection.


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

raw_content: During the walkthrough of the operation, a hanging rod was observed not properly secured in the closet. This is a hazard to the children. The rod can easily be removed and can be used as a weapon.


facility_name: Autistic Treatment Center, Inc.

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

raw_content:
During a review conducted on 03/12/2026 it was determined that: (1) the Administrator failed to ensure compliance with the current HM Plan; and
(2) 12 months had elapsed since the effective date of the plan.  The heightened monitoring plan for this operation included a specific planned end date at the 12-month mark by which the operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of post plan monitoring.  As a direct result of the administrators failure to ensure timely compliance with the heightened monitoring plan, this operation is now unable to successfully move to post-plan monitoring.  Furthermore, the operations planned end date must now be revised, and the period of heightened monitoring must be extended.

Further details of the administrators failure to ensure compliance include the following:
-  Operation failed to satisfy the conditions of the plan
-  Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and
-  Operation was unable to meet compliance with Medium-High or High weighted licensing citations, including having an open investigation.

Correction Narrative: An HM extension was approved effective 3/12/2026.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your GRO in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 748.535(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is 9/13/2026.


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

raw_content: During a heightened monitoring visit on 2/9/26, House 29 there were Clorox wipes on the kitchen counter and one of the cabinets where chemicals are stored above the washer and dryer was left unlocked which contained laundry soap.

Correction Narrative: The operation completed physical site safety and concerns with staff on 02/1126, 02/12/26, 02/20/26, and 03/03/26.  This training focused on ensure home were free of chemical and other physical site concerns so that children in care are safe in their homes.


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

raw_content: A heightened monitoring visit occurred on 1/29/26 and a child's medication log was reviewed. This medication log did not contain initials that three medications were administered on 1/28/26 PM.


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

raw_content: One of the child's medications did not have the name of prescribing physician in the medication record.

Correction Narrative: The new MARS now reflects a doctor's name that is prescribing the medication.  The MAR is continued to being worked on the make it more easily reviewed for all information and should be completed by 03/03/2026.


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

raw_content:
A child's prescription medication was stored in a blister pack created by the operation; however, it did
not contain the same label.

Correction Narrative: An inspection on 02/19/2026 showed all medication was stored in the original container.  The Administrator and management teams are now checking for this during walkthroughs of the home to ensure all medication is stored in original containers weekly.


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

raw_content:
A child's medication record shows that there are 5 prescribed medications, and none have the reason
the medications were prescribed.

Correction Narrative: Medication training was held on 02/12/2026.  The operation MAR sheets now reflect the reason for medication prescribed.


raw_content: There were no initials on who administered two separate medications in two separate days.

Correction Narrative: The new MARS now reflects a signature when the page is turned over and a initial sheet.  The MAR is continued to being worked on the make it more easily reviewed for all information and should be completed by 03/03/2026.


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

raw_content:
A child's medication record containing 5 prescribed medications do not reflect a medication count for
any of the medications.


raw_content: The operation had 60 days from 09/15/25 to acquire a licensed childcare administrator and one was obtained.

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

Correction Narrative: The operation has an administrator and will be added to CLASS on 01/21/2025.  The administrator's first full week was 01/12/2026.


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

raw_content: An adult in care attacked two children in care, a staff, and another adult in care. There is a DFPS investigation pertaining to similar incidents involving the same adult in care.

Correction Narrative: The adult in care involved in this incident was discharged.  Ratio will be increased at any time aggression is being shown.  Policy and procedure training was done with hte home involved in this incident as well as de escalation, supervision, and seperation protocols on 01/26/2026.


raw_content: Noted in a visit was soiled bed linen and strong smell of urine in a home along with clothes scattered in a closet. Observed was a broken barbeque grill in the courtyard. Photographs were taken.

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

Correction Narrative: It was noted during a walkthrough of all three homes that there was no smell of urine. It was noticed that there was a small hole in the soap dispenser in one of the bathrooms. A work order was provided.


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

raw_content: There were three instances that medication was not properly stored that included an unsecured single dose medication blister on the van floor, 10 medication bubble pack cards sitting on a table and medication cups out in an open area.  Photographs were taken.

Correction Narrative: All medications were locked and double locked in all three homes. No medications were noticed in the van that we reviewed.


raw_content: During a walkthrough of House 12, a cabinet in the laundry area containing chemicals was not locked. This laundry room is located in an area that is accessible to children in care.

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


raw_content:
In House 12, a child's headboard was not attached to the frame of the bed and staff confirmed that a child currently slept in that bed. Photographs were taken.

In a separate bedroom, a detached exposed cable was observed in a room that a child with has a history of aggressive behavior.

Correction Narrative: In House 12, the bed that previously had a bed frame with a headboard leaning forward has had the headboard removed. A picture was taken and will be uploaded.


summary: 748.153(3)(B) - Notification - New controlling person

raw_content: Operation's full controlling person information has been requested multiple times and has not been submitted.

Correction Narrative: The operation has added their board members to the controlling person list.


summary: 748.363(12) - Personnel records-For each person who transports a child, include copy of valid driver's license or DPS driver's license check done in last 12 months.

raw_content: During a heightened monitoring visit, a staff member who transports children did not have a copy of their driver's license or driver's license check in their personnel file.

Correction Narrative:
The operation called the employee the day of the inspection and got a current copy of the employee's driver's license. The copy of the license was placed in the employee's personnel folder.

Update 9/31/25: Talked with the operation about where licenses were kept. The operation stated previously they kept licenses with employee I-9s which were not in personnel files. I-9s along with a copy of the driver's license have been placed in employee personnel folders.


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

raw_content: A child in care was left unsupervised outside the operation home.

Correction Narrative:
As of August 28, 2025, the children were returned to standard supervised care immediately.
All direct care staff were provided a refresher training on August 29, 2025, covering:
   Active supervision techniques
   Procedures for transitions
A corrective counseling note was issued to the staff member responsible.

As of August 30, 2025, administration reviewed and revised the staffing schedule to eliminate all gaps in supervision coverage.
Additional staff were reassigned to high-risk transition periods (e.g. transportation to/from school) to ensure continuous oversight.
All staff were verbally re-instructed on supervision requirements.

Follow-up inspection #4081242 conducted 10/16/25.

All direct care staff were provided a refresher training by 9/30/25. A picture of the training curriculum was taken and will be uploaded to the inspection document library.


summary: 748.535(3)(A) - Child-care administrator responsibilities-Overseeing staffing patterns to ensure supervision and child-care services meet the needs of children

raw_content: The operation's staffing schedule allowed children in care unsupervised time outside the home.

Correction Narrative:
As of August 28, 2025, the children were returned to standard supervised care immediately.
All direct care staff were provided a refresher training on August 29, 2025, covering:
   Active supervision techniques
   Procedures for transitions
A corrective counseling note was issued to the staff member responsible.

As of August 30, 2025, administration reviewed and revised the staffing schedule to eliminate all gaps in supervision coverage.
Additional staff were reassigned to high-risk transition periods (e.g. transportation to/from school) to ensure continuous oversight.
All staff were verbally re-instructed on supervision requirements.

Follow-up inspection #4081242 conducted 10/16/25.

The operation has revised their staffing schedule so that a staff is at the homes by early afternoon and can retrieve children in care that arrive back from public school early.


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

raw_content: During an HM visit, the operation could not produce a psychological exam completed on 09/2024 and several months have lapsed.

Correction Narrative: Inspection 7/23/25: Two child records were reviewed, and all documents that were required to be reviewed were in the folder except for medication logs. Medication logs are handled by the school nurses as well as medication binders. The operation stated they are working on consolidating their filing system. They currently have to ask multiple staff where certain documents are and look in different binders. This is an issue with both staff and child records. The operation is looking to have their consolidated filing system in place by the week of September 1st.


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

raw_content: A caregiver was hired in 10/2021 and there was no trauma informed care training until 09/3/2024.

Correction Narrative:
The caregiver received Trauma Informed Care during the current annual year. A follow up plan will be discussed at the next inspection to ensure trainings do not continue to be an issue.

Inspection 7/23/25: Two staff files were reviewed and both staff completed Trauma Informed Care for the current annual year. I interviewed administration about training concerns. They stated now that there is a staff dedicated to training, the operation as a whole is working to consolidate their binder organization process. They stated they are working on having one binder for each staff with Orientation, Pre-Service, and the current Annual Year of Training. They are hoping to have this system in place the week of September 1st.


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

raw_content: A caregiver was hired in October 2021 and there was no psychotropic medication training until 2025.

Correction Narrative:
The caregiver received Psychotropic Medication during the current annual year. A follow up plan will be discussed at the next inspection to ensure trainings do not continue to be an issue.

Inspection 7/23/25: Two staff files were reviewed and both staff completed Psychotropic Medication Training for the current annual year. I interviewed administration about training concerns. They stated now that there is a staff dedicated to training, the operation as a whole is working to consolidate their binder organization process. They stated they are working on having one binder for each staff with Orientation, Pre-Service, and the current Annual Year of Training. They are hoping to have this system in place the week of September 1st.


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

raw_content: During a walkthrough of the operation it was noted that the front gate to home 25 cannot be closed due to a bent lock. It was also noted home 29 had parts of the fence broken.

Correction Narrative: Received pictures of repairs made to the fence and gate. Pictures will be uploaded to the document library for this inspection.


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

raw_content: The EBI training reviewed for three staff members were not completed within the 6 months' timeframe.

Correction Narrative: Dr. Garver sent an email containing the SAMA training certificates for 4 employees that were completed in April. These 4 employees training files will be reviewed during an inspection after October to follow up and ensure EBI training was completed again after 6 months.


summary: 748.949(b)(5) - Annual Training Documentation-Includes the length of the training in hours

raw_content: Three EBI training certificates did not document the number of training hours completed.

Correction Narrative: Dr. Garver sent an email containing updated training certificates that include the hours of training provided. These certificates will be uploaded to the document library.


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

raw_content: One of the homes where children currently reside has missing or damaged fence pickets. There are also visible nails that are not properly driven in. Also, in this same home the skylight in the porch was damaged. Photographs were obtained.

Correction Narrative: Home 29 was observed. I observed the fence to be repaired. Photos were taken. The operation has talked to maintenance about closing the hole in the outside roof as opposed to replacing the plexiglas skylight.


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

raw_content:
During the inspection at the operation:

House 12 had cleaning supplies that were accessible to youth in care in the kitchen, laundry room, under the boy's bathroom sink, and in the closet in the boy's bathroom.

House 29 had cleaning supplies unlocked and accessible to youth in care in the kitchen.

Correction Narrative: Poisons were observed to be locked up at all three facility homes.


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

raw_content: During the walk through of house 12, there were three knives, a screwdriver, and sharp freezer thermometer was unlocked and accessible to children in care.

Correction Narrative: Tools were observed to be locked up and inaccessible in all three facility homes.


raw_content: There was no documented psychotropic medication training for a caregiver during 2023 or 2024.

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

Correction Narrative: An inspection was conducted at the operation and staff files were reviewed. No training concerns were noted. Dr. Garver stated that the operation is still working to get everyone on the same training schedule, but this can be difficult due to the amount of staff.


raw_content: There is no documented trauma informed care training for a caregiver during 2023 and 2024.

Standard Number / Description: 748.930(b)(2) - Annual Training- Caregivers must have 2 hrs trauma informed care.


raw_content: Two employee files were reviewed, and their SAMA training certificates for the previous annual year could not be provided.

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

Correction Narrative: Both employees were observed to have completed SAMA training certificates dated 4/12/2025 at the Heightened Monitoring Inspection on 4/14/2025. The operation stated they are currently working with people to help solidify their employee training schedule so that there are no more missed trainings.


raw_content: During the inspection at the operation, cleaning supplies and other chemicals were observed in the laundry room, kitchen, and closet in the boy's bedroom that were all unlocked and accessible to the youth in care.


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

raw_content: Caregivers were not aware of child's on-going activity, which led to inappropriate contact with residents.

Correction Narrative: The operation implemented a safety plan to ensure there is a response to motion detectors. The staff and children in care were provided additional training/coaching on privacy and intervention.


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

raw_content: When reviewing annual training hours, it was found that two employees had not completed Normalcy training, and one employee's Trauma Informed Care training had expired on June 9, 2023.

Correction Narrative: Compliance was met when the operation provided training certificates of the required trainings that were missing for each staff member.


summary: 748.3393(d) - Toilets-Toilets must be equipped with toilet paper at all times

raw_content: One of the two bathrooms did not have toilet paper in the bathroom. This was corrected at Inspection, when staff put toilet paper in the bathroom


summary: 748.455(a)(2) - Unauthorized AbsenceDebrief include trauma informed strategies child can use to avoid future unauth absences & how op. can support strategies

raw_content: An SIR report does not document a debriefing with the child.

Correction Narrative: Staff was trained on behavioral techniques on 7/5/2024 the operation submitted a waiver/variance due to children not having the cognitive functioning to understand debriefing.


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

raw_content:
14- and 16-year-old children in care were left unsupervised by a caregiver. This resulted in a physical altercation, damaged property, and self-harm.

At an inspection completed on 1/3/2024, this standard was evaluated for compliance and found to be compliant, the operation terminated the staff member involved in the incident.

Correction Narrative: On 1/3/2024 RCCR conducted an inspection at the operation, the operation came into compliance by terminating the staff member.


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

raw_content: Children in care's supervision plan required constant supervision. This plan was not followed by direct care staff.

Correction Narrative: On 1/3/2024 RCCR conducted an inspection at the operation, the operation came into compliance by terminating the staff member. In addition the operation submitted a plan to retrain staff on the supervision policy on 1/11/2024.


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

raw_content: Five of five child's records reviewed contained service plans that were missing required signatures.

Correction Narrative: Dr. Graver emailed the children's service with updates and the operations plan to ensure the service plans will be updated every 90 days.


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

raw_content: Three of the five child files reviewed contained service plans that did not indicate if the child participated in the service plan.


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

raw_content: Four of the five child files reviewed contained service plans that were not completed every 90 days.


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

raw_content: Five of the five child files reviewed contained service plans that did not have two professionals participate.


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

raw_content: A child in care touches a caregiver's back. The caregiver turns and gestures as if to hit the child due to this interaction.

Correction Narrative: The child was observed by RCCR on 06/07/2023, no concerns were observed. On 06/21/2023 a corrective action place was implemented by the operation. The staff member was provided behavior intervention training and the worker's capability to continue working with OV was assessed. The operation is requesting an administrative review.


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: The child's prescription required that Pediasure, Risperidone and Clonidine should be given 3 times daily. Methylphenidate was prescribed daily. This recommendation was not being followed.

Correction Narrative: On 5/11/2023 this inspector received an email from the Director stating that the staff that did not document the medication administration has retaken the medication refresher training and certificates were provided.


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: The operation had not validated their person list in the last 12 months.

Correction Narrative: This inspector received an email on 5/11/2023 from the Director stating she spoke with the HR Director, and she validated the staff in the system and in the future, HR will validate the employees quarterly. HR will post the dates on the administrative calendar as a reminder to validate the employees. CLASS showed the last validation date was on 05/09/2023.


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

raw_content: Of the five child files reviewed, two had a service plan team meeting invite that was not sent out to the CPS worker.

Correction Narrative: A plan was put into place to ensure service plan emails will be sent out to CPS Workers.


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

raw_content: Numerous medication logs did not document the prescribing physician's name, the reason for the medication or the administration of the medication.

Correction Narrative: An email was received with the following corrections physician's name, the reason for the medication, the administration of the medication, and a plan to ensure the accuracy of the medication logs in the future.


summary: 748.1101(b)(6)(A) - Child rights-medical,dental,vision,MH,develp services that meet child need. Right to request services separate from adults who receive services

raw_content: The CANS Assessment for 5 children in care recommended that the child participate in Case Management and Skills Training and see a Developmental Disability Specialist these services were not being provided to the child.

Correction Narrative: A plan was emailed on how the operation will ensure that the children's services will be completed.


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

raw_content: There were 2 staff members that did not complete Trauma Informed Care training in 2021.

Correction Narrative: Staff members' Trauma Informed Care training certificates.


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

raw_content: During the walk through of all four resident homes there were broken blinds, a hole in a closet door, mold in two bathrooms, a broken soap holder in one shower, and numerous used cigarettes butts on ground outside one home.


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

raw_content: The facility has not been documenting unauthorized absences.

Correction Narrative: An email was received from the agency containing a copy of the agency's unauthorized absence log which the agency will now use when needed. The email also stated a certain person has been designated as the person responsible for filling out the unauthorized log, as soon as the person is notified they will complete the log.


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

raw_content: Serious incident reports were not being documented.

Correction Narrative: An email was received from the agency containing recent serious incident reports that had not been filled out prior. The email also stated a certain person has been designated as the person responsible for filling out all serious incident reports; as soon as the person is notified they will complete an SIR.


summary: 748.363(10) - Personnel records-For each person who transports a child, include copy of valid driver's license or DPS driver's license check done in last 12 months

raw_content:
One employee who has been transporting children has an expired drivers license.

The agency came into compliance during the inspection by having the employee sign a statement that he would not transport children in care until he provides the facility with a copy of his updated and current driver's license.


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

raw_content: Multiple medication logs reviewed did not have the prescribing professional's name or the reason the medication was prescribed documented on the log.

Correction Narrative: An email was received from the agency. The medication logs have been updated to include the prescribing doctor's information.


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

raw_content: Of the three child files reviewed, one child's file did not have the Child Right's form signed by the child and one child's file did not have the form.

Correction Narrative: The agency sent an email with the signed and dated Child's Rights form. The agency stated they also received a blank copy of the form to keep on hand in the event CPS does not bring the form when new placements are done.


summary: 748.2101(4) - Medication Storage-make provisions for storing medication that requires refrigeration

raw_content:
There was one prescription medication that was in the refrigerator not locked up.

While at the facility, the medication was placed in a locked box and placed back in the fridge.


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

raw_content: A child in care hit a staff member multiple times. The staff member did not implement a restraint.

Correction Narrative: Staff and caregivers participated in additional training/retraining in emergency behavior intervention (EBI) de-escalation procedures and blocking pad use. Staff and caregivers were also retrained in assisting other staff during an intervention. The staff member involved in this incident has also been terminated.


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

raw_content: A child in care ran out of the room after being slapped. Two staff members observed this incident and did not respond.

Correction Narrative: Staff and caregivers participated in additional training/retraining in emergency behavior intervention (EBI) de-escalation procedures and blocking pad use. Staff and caregivers were also retrained in assisting other staff during an intervention.


raw_content: Physical discipline was used on a child in care.

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

Correction Narrative: The staff member involved in this incident was terminated. All other staff and caregivers participated in additional training/retraining in emergency behavior intervention (EBI) de-escalation procedures and blocking pad use. Staff and caregivers were also retrained in assisting other staff during an intervention.


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

raw_content: A 14 year old child in care sustained injuries to the face from being slapped by a staff member.


summary: 748.3365(a) - Bedding-must provide each child with an individual bed or bunk bed in child's room that elevates mattress off floor, or crib as appropriate

raw_content: In one of the homes it was observed that a child was sleeping on a mattress on the floor.


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 had a safety plan in place stating he would remain in line of sight supervision but this was not followed by the caregiver which resulted in the child injuring another child in care.

Correction Narrative: The child's service plan has been updated regarding the child's specific supervision needs and requirements.


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

raw_content: A child's service plan is not tailored to their individual and specific supervision needs.


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

raw_content: A child in care took another child's medication.


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

raw_content: Children in care were left unattended with distributed medication.


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

raw_content: A staff member has used inappropriate language around children in care multiple times and has made inappropriate remarks to children in care.

Correction Narrative: Email received from the agency stating management had talk meeting with the staff involved and the staff will no longer be allowed to work with children at the facility.


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

raw_content: On 06/20/2021 A Direct Care Worker, who recently failed to supervise a child appropriately, left a child in care unattended again. The Direct Care Worker took a shower. The child's service plan required constant supervision to prevent aggressive behaviors and elopement. While unattended the child walked 3 miles away from the facility.

Correction Narrative: Email was received from the operation containing a compliance plan. The compliance plan stated the staff member has officially been terminated, a meeting was held with management staff, meeting was held with house staff on 8/20/21 where they discussed the importance of line of sight supervision, additional staff will be added when needed, and room assignments were modified.


raw_content: On 06/19/2021 a Direct Care Worker grilled food outside of the home. This act left a 15 year old child  in care unattended. The child in care had a history of aggressive behaviors. While unsupervised the child in care engaged in inappropriate sexual contact with an adult in care.

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


summary: 748.3421(3) - Poisons-Ensure poisonous or flammable materials are inaccessible to children unless child has been evaluated as capable & likely to use responsibly

raw_content: Multiple cleaners and chemicals were observed to be accessible to children.


raw_content: One child's file reviewed did not have the Child's Rights form signed by the child.

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


summary: 748.363(8) - Personnel records - Include signed dated statement by the employee that he must immediately report suspected child abuse, neglect, or exploitation.

raw_content: Two employee files did not have a signed statment for reporting suspected abuse or neglect.


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

raw_content: Homes were inspected and were found to have multiple chairs with rips/holes, one door with a hole, and lightswitch plates coming off the wall.


facility_name: Unity Childrens Home

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

raw_content: Fire inspection expired on 10/2/2024.

Deficiency Narrative: Fire inspection expired on 10/2/2024.

Correction Narrative: On 7/30/25, The operation provided a copy of the updated Fire Inspection, dated 3/21/25. The inspection lists a number of corrections which were required of the operation.  However, the inspection was completed within the past 12 month and brings this standard into compliance.


facility_name: The Pride Lands Center of Hope

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

raw_content: It was determined that a staff member threatened a child in care with the use of mase.

Correction Narrative:
As per the Administrator, at the time of the incident, the staff member subject to this investigation did not have further contact with the child in care following the incident. The incident was documented and reviewed by Administration. Staff were reminded that threats, intimidation, or references to weapons or chemical agents are strictly prohibited. The staff member subject to this investigation was formally written up in accordance with agency disciplinary policy. All direct care staff will complete refresher training as scheduled on child rights, trauma-informed care, professional conduct, and approved de-escalation techniques. The Administrator will conduct monthly supervisory observations and review incident reports to ensure staff utilize approved, non-threatening interventions and noted that any future violations will result in immediate investigation and corrective action. Quarterly training and ongoing supervision were implemented and expectations regarding respectful communication and appropriate behavior management will be reinforced during staff meetings to maintain a safe and therapeutic environment.
On 02/02/2026, an unannounced inspection was conducted at the operation. Please see Chrono.


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

raw_content: One of two staff files did not have a required drug test. One staff file had a drug test months after hire date.

Correction Narrative: As per the CEO/Executive Director, the operation has assigned the HR Coordinator to ensure that all applicants prior to being hired will have passed pre-employment drug testing with the results of the testing documented.


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

raw_content: One of two staff files did not have documented employment verification and both files did not have reference checks.

Category: Personnel

Correction Narrative: As per the CEO/Executive Director, the operation has assigned the HR Coordinator to ensure the organization remains in compliance with the minimum standards. Employment verification will be documented, and the information will be written for each reference checked and noted on TPLCOH employment verification form.


summary: 748.881(3) - General pre-service training curriculum-Includes procedures to follow in emergencies

raw_content: Two of two staff files reviewed not have any training related to any type of emergencies and/or communicable diseases.

Correction Narrative: As per the CEO/Executive Director, the operation's Administrator has delegated the HR Coordinator/Training Coordinator, to ensure that all pre-service and annual trainings include signature pages, and post-test documentation to convey understanding of the information following trainings. The HR Coordinator will conduct CQI assessments monthly to ensure all employees have satisfied these requirements.


summary: 748.1937(a)(4) - Adult in care may share room with child in care if child is 16 years old, age difference does not exceed 24 months; req. of 748.1931 and 1933 are met

raw_content: It was determined that an adult in care is sharing a bedroom with a child younger than 24 months.

Category: Providing Children and Adult Care

Correction Narrative: As per the CEO/Executive Director, the operation has assigned Program Director to ensure that any adult resident in care will not share a room with any child at any time whose age difference exceeds 24 months.


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

raw_content: Two of two staff files did not have the required document.

Correction Narrative: As per the CEO/Executive Director, the operation designated the HR Coordinator to ensure the organization remains in compliance with minimum standards. Form 2912 has been added to TPLCOH new hire packet.  All new hires will be required to complete before employment is confirmed and begun.  Additionally, each current employee has completed form 2912 and a copy has been placed in their employee binder.


summary: 748.869(c) - Training on administering psych. medication must be instructor-led. The instructor must be a health-care professional or pharmacist.

raw_content: Two of two staff files did not have the training instructor-led requirements relating to psychotropic medication training. Two or two staff files did not have any evaluation and/or assessments relating to EBI trainings.

Correction Narrative: As per the CEO/Executive Director, the operation has designated the LCCA/Administrator to ensure that all personnel who administer medications will receive instructor-led training by licensed personnel from the pharmacy used by the operation prior to being entrusted with those responsibilities. The Pharmacist of Record has scheduled training with TPLCOH personnel dated 06/03/2025. Documentation will be provided upon completion of training.


summary: 748.861(b)(3) - Pre-Service Training - Supervised experience must be documented in personnel record

raw_content: Two of two staff members did not have the required childcare experience. Both staff did not have the required shadowing of another caretaker.

Correction Narrative: As per the CEO/Executive Director, the operation's HR Coordinator has ensured that all personnel have a minimum of 40 hours on-site training and shadowing within the facility of TPLCOH. These hours have been documented as training on our schedules.  Going forward the HR Coordinator will ensure that pre-service training/shadowing will be documented on the provide tracking document for all new hires prior to being alone with children in our care. Schedules provided showing training onsite hours.


summary: 748.3443(b)(2) - Food Preparation-Must have a thermometer in freezers & store frozen food at 0 degrees Fahrenheit or below

raw_content: The thermometer is both the freezer and refrigerator are not fuctioning.

Correction Narrative: The Pride Lands Center of Hope shall designate Abram Chizer  Staff Supervisor to ensure the organization remains in compliance with minimum standards.  A daily log sheet has been created and is prominently displayed for staff once a day to log the thermometer reading of both the freezer and the refrigerator.


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

raw_content: The operations health inspection has expired.

Correction Narrative: The Pride Lands Center of Hope shall designate Thurman Outley  Program Director to ensure the organization remains in compliance in ensuring sanitation inspection will be conducted at least once every 12 months. Mr. Outley will conduct quarterly checks and will schedule an Sanitation inspection at least 30 days prior to expiration to ensure any deficiencies can be addressed prior to the current certificates expiration


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

raw_content: A staff with an ineligible background check was present at the operation & in contact with children in care.

Correction Narrative: The Pride Lands Center of Hope has designated Thurman Outley -Director to ensure that no employee will be present in the operation with access to children until a CBCU background designation allowing such a presence at the operation.


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

raw_content: Medications were observed prepackaged in a zip lock bag.

Correction Narrative: The Pride Lands Center of Hope has designated Thurman Outley -Director to ensure that all medication will be stored in its original packaging unless there is an additional container with the same label and administering instructions.


summary: 748.2003(b)(4) - Administration of prescription medication-Administer each child's medication within one hour of preparation

raw_content: Medications prepared the day prior, were observed prepackaged in a zip lock bag.

Correction Narrative:
The Pride Lands Center of Hope has designated Thurman Outley -Director to ensure
that each child's medication will be administered within 1 hour of preparation.


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

raw_content: The operation did not follow the supervision outlined in a child's service plan.

Correction Narrative: The Pride Lands Center of Hope shall designate Litha Tucker -Administrator and Verily Harris-Harper -Treatment Director to ensure that each child's service plan is followed as agreed upon.


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: Child/Caregiver ratio was not in compliance during waking hours.

Correction Narrative: The Pride Lands Center of Hope shall designate Litha Tucker -Administrator to ensure the organization remains in required ratio according to the clients Service Plans and minimum standards.


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

raw_content: Records reviewed were not consistent with verbal reports.

Correction Narrative: The Pride Lands Center of Hope shall designate Litha Tucker -Administrator to ensure that all record details are true, accurate and complete.


raw_content: It was found that the operation sanitation inspection has expired.

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

Correction Narrative:
The Pride Lands Center of Hope shall designate - (Thurman Outley-Director) to ensure
Sanitation Inspection officials will complete inspections annually, (not later than 12 months from
the previous inspection). The Pride Land's Center of Hope shall contract inspection services
through licensed sanitation and health organizations only.


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

raw_content:
During inspection 1 out of 3 children in care records was missing signature for child rights.

Corrected at inspection. Staff was able to have child in care sign child rights


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

raw_content: During inspection it was observed unauthorized absence log did not generate the proper information to document unauthorized absence correctly.   Director provided the correct unauthorized absence log sheet.