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

raw_content: 1 of 4 medication records for one child was missing proper documentation for medication administration.

Correction Narrative: The agency conducted a staff meeting to inform staff to ensure all medications are properly administered and all records regarding medication administration are clear and accurate to provide up-todate. Staff was informed to sign for medications administered when administered. Staff signed for the medication on February 21, 2023. Medication logs will be checked frequently throughout the day.


state: TX

facility_name: Amor Purus LLC

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

raw_content: One of four staff records read did not contain a TB exam.

Category: Individual Standards Evaluated

Standard Risk Level: Medium Low

Corrected at Inspection: No

Correction Narrative:
The agency developed a spreadsheet to track items needed for personnel file. The spreadsheet will be viewed weekly to ensure items are in the file. The spreadsheet will be available upon request.The TB skin test
was uploaded to the file on February 21, 2023.


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

raw_content: 2 of the 3 staff records reviewed had Licensing Affidavits that are not notarized.

Category: Reports and Record Keeping

Standard Risk Level: Medium

Correction Narrative: The operation sent an email providing a copy of the staff's notarized Licensing Affidavit.


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

raw_content: A child's medication and medication record indicates that a child has not taking his medication since 5/17/2022.

Category: Medication

Standard Risk Level: Medium High

Correction Narrative: The operation sent an email showing pictures of the new way medications will be provided. The operation got the pharmacy to switch up the medication packs, ensuring that each child get their required medications daily, to avoid missing any doses. They also sent a plan stating, "All medication have been taken to Bemaj Pharmacy where they were placed in blister packets and given for a 30 day count. From this day going forth Bemaj Pharmacy will continue to blister package all medication for the children and deliver to the home. This will cut out the need of employees having to package or group the medication for the children. In addition, the date that the blister was administered is also recorded under numerical number on the blister package. "


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

raw_content: Staff records did not include date of employment.

Correction Narrative: The operation sent an email with a picture showing the employees date of employment.


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

raw_content: 1 staff record reviewed did not include cleared TB test.

Correction Narrative: The operation provided an email with the staff's TB screening attached.


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

raw_content: Employee records did not include a sign statement stating they have read the operation's policies.

Correction Narrative: The operation sent an email with signed copies of statements from staff showing they have read the operation's policies.


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

raw_content: One child's medication record reviewed showed that the child started a new pack of medication on 5/18/2022, but there was no medication to validate that.

Category: Organization and Administration

Correction Narrative: The operation provided documentation showing that the staff has been retrained on medication, including their office manager who will be in charge of ensuring the documentation is correct. They also provided a plan stating, "All medication have been taken to Bemaj Pharmacy where they were placed in blister packets and given for a 30 day count. From this day going forth Bemaj Pharmacy will continue to blister package all medication for the children and deliver to the home. This will cut out the need of employees having to package or group the medication for the children. In addition, the date that the blister was administered is also recorded under numerical number on the blister package. "


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

raw_content: Some of the children's medication records were missing the medication counts.

Correction Narrative: The operation provided documentation showing that all staff have been retrained on medications. The staff were retrained on 5/25/2022.


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: 4 of the 4 employee records does not include a signed statement stating they will report suspected abuse/neglect.

Correction Narrative: The operation provided a picture of the document.


raw_content: 4 of the 4 employee records reviewed did not have a signed Licensing Affidavit

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


summary: 748.3001(a) - Sanitation Inspection-State or local sanitation official must conduct a sanitation inspection

raw_content: There has been no sanitation inspection completed for the operation

Category: Safety and Emergency Practices

Corrected at Inspection: Yes


summary: 748.105(5) - Personnel Policies - Develop written policies on whether caregivers may take children away for  day/overnight visits, ensure policy meets requirements

raw_content: There is no policy on whether or not the operation allows caregivers to take children in care away from the operation for day or overnight visits.

Correction Narrative: The operation provided an updated policy that addresses whether caregivers can take children away for day and/or overnight visits.


summary: 748.111(5) - Child-care policy - How a child obtains clothing

raw_content: There is no policy on how the children will obtain clothing.

Correction Narrative: The operation emailed an updated policy that includes information on how children in care will obtain clothing.


summary: 748.109(1) - Admission Policies - Include program's goals and services provided, including whether emergency admissions accepted

raw_content: Admission policy does not state the operation's goals and services the operation will provide and does not describe the type of treatment services. Also does not include whether or not the operation will accept emergency admissions

Correction Narrative: The operation emailed an updated admissions policy.


raw_content: child admission form included the name of another operation.

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

Correction Narrative: The operation provided an updated admissions form with the name of the other operation removed.


summary: 748.111(4) - Child-care policy - Child's right to receive and give gifts

raw_content: There is no policy on child s right to receive and give gifts

Correction Narrative: The operation emailed an updated policy that includes detailed information on the child's right to give and receive gifts.


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

raw_content: EBI policy does not tell how the operation will explain and document to a child who can use EBI in a way the child can understand

Correction Narrative: The operation email an updated EBI policy.


summary: 748.127(a) - Operation plans, policies and procedures must indicate date adopted and effective date

raw_content: Policy does not have an effective date

Deficiency Narrative: Policy does not have an effective date

Correction Narrative: The operation sent an email with their updated policy showing the effective date.


summary: 748.531(b) - Child-care administrator-If acting as administrator for two operations, split full-time schedule per professional staffing plan for each operation

raw_content: professional staffing plan did not address the administrator splitting a full time schedule between the to operations.

Category: Personnel

Correction Narrative: The operation provided a plan on how the LCCA plans to split her full-time schedule.


summary: 748.1209(b)(1) - Child Orientation-Include policies on visitation, including family visitation & overnight visitation

raw_content: child orientation did not include all required components.

Category: Admission, Service Planning, Discharge

Correction Narrative: The operation emailed an updated policy that addresses family visitation and overnight visitation.


summary: 748.121 - Abuse and neglect policy - You must develop policies on preventing, recognizing, and responding to abuse and neglect of children

raw_content: There is no abuse and neglect policy

Deficiency Narrative: There is no abuse and neglect policy


summary: 748.105(3) - Personnel Policies - Develop written professional staffing plan

raw_content: Professional staffing plan is not sufficient as it did not give enough detail on how the staffing patterns will meet the needs of the children in care. It also does not provide enough detail on part time employees.

Correction Narrative: The operation emailed an updated policy that included an updated staffing plan.


facility_name: Special Parent Advocacy Group A NJ Nonprofit Corporation

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

raw_content: A child in care medication log was not signed by staff. The medication log was seen in the child's binder.

Correction Narrative: An email was received from executive director on 2/27/2026 showing that staff did sign medication log.  The staff signatures can be seen on page 2.  The sign medication log can be found in the document library.


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

raw_content: There were two bedrooms that are designated for male children that is not near a restroom. The children have to walk through the case manager's office, living room, two hallways and the master bedroom to reach the restroom that is designated for them.

Standard Risk Level: Low

Correction Narrative: A walk-through was conducted at the operation. There were no concerns seen during the walk through regarding bathrooms.tm


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

raw_content: The grass in the backyard needed to be mowed and there was a tree in the middle of the property that had fallen.

Correction Narrative: A walk-through was conducted outside of the operation. The grass in the backyard was cut and there was not a tree seen in the middle of the property.tm


summary: 748.1433(e) - Discharge-If child receiving tx svcs, tell him of planned discharge/transfer 4 days in advance, unless qualified professional justifies not doing so

raw_content: A child in care was not notified about their discharge.  The discharge summary also did not indicate that the child's service plan's for the last 12 months were provided to the person who the child was discharged too.

Correction Narrative: An email was sent from administrator showing both case managers receive training regarding discharges. Both training certificates can be found in the document library.


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

raw_content: The written incident report still does not include the phone number for the operation.

Correction Narrative: 1/26/2026: The executive director emailed the updated incident report that now includes the phone number.


summary: 745.8641 - Requirements during probation

raw_content:
Condition 1: Met

Condition 2: No met.  A training for a staff member expired in December and there was no documentation showing the staff was notified of her expired training or when they were due.

Condition 3: Met

Condition 4: Not due yet.

Condition 5:  Not met. There were two noted concerns by a youth with no plan to follow up on the concerns.

Standard Risk Level: High

Correction Narrative:
1/23/2026: Condition 2: The notification that was sent to the employee regarding their training on 1/14/2026.  The staff was instructed to have the training completed by 1/30/26.

1/26/2026: Condition 5: The executive director emailed showing all observers and reviewers have been notified that the youth's concerns and follow ups must be documented.  The Docusign document is also being updated to reflect these updates.


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 that was required 1:1 supervision was left unsupervised with another child resulting in inappropriate contact between the children.   The children were also allowed to be on the couch together under blankets.


summary: 748.2953(a) - Evaluation-Quarterly, operation must collect, document, & review aggregate numbers of emergency behavior interventions by type of intervention

raw_content: EBI Quarterly reports were not submitted for the 1st, 2nd and 3rd quarters.

Category: Emergency Behavior Intervention

Correction Narrative:
01/13/2026: Verified through the CLASS reports that Q1, Q2, and Q3 have been submitted for 2025.

12/18/2025: The operation emailed that this task is now assigned to an assistant case manager and an the google calendar.


summary: 748.2855(a)(6) - EBI Documentation-Must include the length of time the child was restrained or secluded

raw_content: One report reviewed indicated two restraints were used on a child and both restraints did not have a time documented for how long the restraints lasted.

Correction Narrative: 12/18/2025: The operation emailed a plan of compliance.  The executive director will now be reviewing reports after they are signed.  The operation is also moving to an electronic submittal and review system.


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

raw_content: The incident report reviewed had incorrect documentation on whether the child loss consciousness or not.    Also, the EBI reports did not document the restraints as separate documents.

Correction Narrative: The administrator emailed stating all staff have been retrained on incident reporting completion.


raw_content:
Condition 1- Compliant
Condition 2- The operation's timeframe to implement this condition has not expired. Pending Review.
Condition 3- Compliant
Condition 4-The operation's timeframe to implement this condition has not expired. Pending Review.
Condition 5- Deficient-. The observation forms did not include the signature of the Governing Body within 48 hours of the observation. The observation log did ensure that all observations were conducted by the Administrator, Designee on record, or Designated person in Management (not to include Direct Staff or Direct Care Supervisors). The observation did not evaluate the interactions of the Direct Care Supervisors, Caregivers, and Children in Care

Standard Number / Description: 745.8641 - Requirements during probation

Correction Narrative: The operation provided RCCR with the signed the observation forms. The signed observation forms are uploaded into the documentation library.


summary: 748.2651(a) - Seclusion-Caregivers must continuously observe the child; use of window or one-way mirror allowed; use of video camera not permitted

raw_content: The entry/exit doors to a room have child locking devices on the doorknobs. This room was used to isolate a child while escalated. The child was left alone in the room without a method to supervise. The operation is not permitted to provide seclusion services as a behavior intervention.

Correction Narrative: RCCR conducted a team inspection at the operation, the administrator and director reported to not using the sensory room as a seclusion room but a sensory-time out room, they both were unaware of the doorknob cover being place on the door, however during the inspection the doorknob cover was not on the door, the operation plans to remove the door. The photo of the door removed is uploaded into the documentation library.


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

raw_content: A caregiver restrained a child by placing both arms behind the back.

Correction Narrative: RCCR conducted a team inspection at the operation both the administrator and director were present; the operation agreed to no longer use the handle with care manual and will have a refresher CPI training for all staff.


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

raw_content: A child in care was not given his prescription eye drops as instructed by the doctor.

Correction Narrative: The child involved was discharged from the operation. An inspection conducted on 05/06/2025 reviewed the operation's compliance with medication administration and did not find deficiencies.


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

raw_content: The medication log did not have a specific time as to when the medication was given.

Correction Narrative: RCCR conducted an inspection at the operation, the operation met with staff on the importance of giving the children their medication in timely manner, the operation wrote the staff members involved. The child who was receiving insulin is no longer in care and the operation reporter they currently do not have any placements receiving insulin however insulin/diabetes training is still being implemented.


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

raw_content: A staff member did not complete annual trainings in a timely manner nor by the required time frame.

Correction Narrative: The operation provided RCCR a written to ensure staff members training are completely in a timely manner.


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

raw_content: Multiple medication logs reviewed did not have the reason medication was prescribed.

Correction Narrative: RCCR conducted an inspection at the operation, the operation re-trained staff on the importance of adding the reason medication is prescribe, the operation wrote the staff members up that were responsible for the error.


raw_content: The child in care did not receive his insulin according to the management plan.

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: 748.2203(a) - Medication Error-If prescription medication, contact a health-care professional immediately & follow health-care professional's recommendations

raw_content: A child did not receive their medication for 03/13/25 and there was not a documentation addressing the error completed.

Correction Narrative: RCCR conducted an inspection at the operation, the operation trained the staff on the importance of documenting medication errors, the operation wrote the staff members who was responsible for the error.


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

raw_content: A child in care requires 1:1 supervision. The child is being provided line of sight supervision.

Correction Narrative: A child in care requires 1:1 supervision. The child is being observed as line of sight.


summary: 748.2003(b)(6) - Administration of prescription medication-ensure a person trained in & authorized to administer prescription medication administers the medication

raw_content: A staff member provided medications to a child in care without being trained.

Correction Narrative: A safety plan was completed and returned to RCCR indicating that only the LCCA and Management would provide medications to OV. A follow up inspection was completed at the operation on 02/25/2025 to ensure compliance is being kept regarding all medications.


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

raw_content: Two children files did not have TB Test results

Category: Child Care


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: Personnel file support that trainings were completed online through DFPS. The instructor lead portion is not being completed by a medical professional.

Category: Training and Professional Development


summary: 748.1545(b) - Vision and hearing screening - Results on file for child, or parental statement that school has records or screening should not be done

raw_content: The three children files reviewed did not have vision or hearing exams.


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

raw_content: The Treatment Director's case file does not support a hire date. The case file also is missing numbers 3, 4, 6-9, and 11-14 of this rule.


summary: 748.911(c)(1) - Each caregiver must be certified in first aid within 90 days of employment.

raw_content: 1 out 3 staffs files didnt have thier First Aid completed.


summary: 748.2005(b) - Medication Orders-A verbal order must be documented in the record, including the health care professional's name, date and time of call

raw_content: On January 12, 2024 medical documentation indicates that a child should take Ondansetron and fluocinolone to manage their medical condition. These prescriptions were not filled by the operation.


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: Child in care was hit by a staff member.

Correction Narrative: Staff member was terminated. Operation will retrain all staff members of proper handling techniques with children in care. Sign in roster will be provided on 03/06/2024 by administrator.


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

raw_content: The caregiver did not use prudent judgement when distributing medication to two non-verbal children in care, resulting in the children receiving the wrong medication.

Correction Narrative: The agency has implemented a new process that will be in effect if the same situation ever arises. They will make sure that the siblings have name tags placed on the back of their shirts so that the children can be identified more easily.


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: Prescription medication for two siblings was administered incorrectly which resulted in one sibling being given the other siblings medication.

Correction Narrative:
Medication was restricted to select staff only
both brothers are to wear provided name labels at all times, which were placed on the back of their shirts so that they could not remove them.
Administrator periodically quizzed staff on all shifts on the identity of each brother.

This was in effect for two weeks, so that the staff could get familiar with the boys, but will be effective in the future if this situation ever arises again.


summary: 745.635(3) - AP Background ck determination - If provisionally eligible w/conditions or eligible w/conditions you must restrict duties per conditions/restrictions

raw_content: A staff member with a provisional status is not following all the conditions of the restrictions by administering medication to children.

Correction Narrative: The administrator send a plan staff was not administering medication until background check was clear. Admin staff will review conditions with staff in the future. Current staff is no longer on provisional.


summary: 748.863(a)(3) - Caregiver for child-care or prog. svcs only must have 8 hours EBI training, 4 before counted in ratio, rest in 90 days; 16hrs for treatment svcs

raw_content: A staff member who was using EBI on a child in care was assisted by a staff member who was not trained in EBI.

Correction Narrative: A copy of the training staff attended on November 5 and 6, 2023 was provided to Inspector.


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

raw_content: Two staff members were not properly supervising a child who was attempting to cause harm to own wrist and was able to gain access to an item and place around the neck.

Correction Narrative: The administrator conducted a staff meeting on 11/8/23 to discuss supervision with the staff.


summary: 748.363(11) - Personnel records-Include record of training and training hours

raw_content: Employee records missing ceritifcations or memorandum of training completed per minimum standard requirement.

Correction Narrative: All training and drug testing were completed by the operation and submitted in PDF file to the licensing representative on 07/28/2023. All documents have been uploaded to SharePoint on 07/28/2023. The administrator will correct these deficiencies by ensuring all personnel complete a drug test prior to being employed by creating a checklist that will go in front of their file. The administrator will also create a checklist to ensure all training is completed before an employer can provide direct care to any child in care.


facility_name: TRELS Home for Children

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: During the review of one childs file, it was noticed that the 2 weeks child plan of service notice was  sent to DFPS staff on 8-27-25 and the meeting date is suppose to be 8-29-25 (2 days before the child plan of service meeting).

Correction Narrative: Follow up was completed by inspection at the operation. Staff Ms. Helen stated that they rescheduled the child plan of service to 9-26-25 at 3pm. Notice to DFPS caseworker was sent September 12th, 2025. Copy of the sent invite email to DFPS caseworker was presented to me and photo taken. She stated that moving forward that case manager supervisors will ensure that 2-weeks notice is sent to DFPS caseworkers timely.


raw_content: A staff member whose background check conditions state she cannot administer medication, does so at the operation.

Standard Number / Description: 745.635(3) - AP Background ck determination - If provisionally eligible w/conditions or eligible w/conditions you must restrict duties per conditions/restrictions

Correction Narrative:
Corrections submitted. Operation Administrator reported that supervisors have been re-trained on provisional status background checks as of October 25, 2023.

Location: TRELS Homes 504 W. Lewis, Spring, Texas.

How To Prevent from Happening in the Future:

Trels will not allow employees with provisional background check status to be in ECP (medication management system) so they do not accidentally clear no pass alerts.


summary: 748.1101(b)(4)(A)(vii) - Children's rights- Free from demeaning behavior to embarrass/control/harm/intimidate/isolate the child

raw_content: During the course of this investigation this standard was found to be deficient due to multiple children in care reporting that a caregiver touched a child in care inappropriately.

Correction Narrative: Follow-up conducted on 11.21.23 and TRELS operation is in compliance effective 10.4.23.


raw_content: During the course of this investigation this standard was found to be deficient due to a caregiver taking the children inappropriate areas during outings and also asking children to buy her things.

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


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

raw_content: During the course of the investigation this standard was found to be deficient due to the operation being notified by a child in care that they there were possible behaviors of abuse or neglect by a staff and the incident not being reported timely.


raw_content: During the course of the investigation this standard was found to be deficient due to the operation receiving an RTB PHAB, NSUP and SXAB.

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: 748.1661(c) - Tobacco Products-Adult may only smoke tobacco products, e-cigarettes, or vaporizers on premises at a safe distance from child living area

raw_content: During the course of this investigation this standard was found to be deficient due to multiple children reporting that a caregiver smoked and vaped in their presence at the operation, during outings and inside the operation.


summary: 748.1661(a) - Tobacco Products and E-Cigarettes -Children may not use or possess tobacco products, e-cigarettes or any type of vaporizers

raw_content: During the course of this investigation, it was found that this standard was deficient due to a caregiver allowing children to vape and smoke and even offering it to them.


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

raw_content: Four medication logs were observed with documentation inaccuracies. In addition, the Organizational Chart had not been updated.

Correction Narrative:
TRELS Has implemented a practice that requires all medication changes reasons to be typed onto the MAR to make med changes easier to see to RCCR and DFPS
TRELS Has requested an administrative review for this deficiency.


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: From July 8th-11th, one child's medication log showed she was receiving 15mg of Aripiprazole once a day, when the prescription stated she should receive 15mg twice a day.

Correction Narrative:
TRELS Has implemented a practice that requires all medication changes reasons to be typed onto the MAR to make med changes easier to see to RCCR and DFPS
TRELS Has requested an administrative review for this deficiency


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

raw_content: The refrigerator temperature read 46 degrees and the deep freezer temperature read 17 degrees.

Category: Physical Site


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

raw_content: 4 of 4 service plans did not include specific information regarding supervision requirements for each resident. Frequency of checks, when not in staff's sight, not included in service plan.

Correction Narrative: TRELS Home for Children will add the definitions of the words to the preliminary service plan.  TRELs does not agree with this deficiency as the standard was met; however licensing is recommending that more information be added for Licensing's understanding of the document.  TRELS Home staff complete a check and form every 30 minutes indicating what the child is doing and that they have been monitored.  This also has been added to the Service plan to ensure licensing understanding of TRELS practices. TRELS Home for Children takes supervision seriously.  We add supervision requirements for each individual child that is placed and we ensure staff are trained on our supervision levels. TRELS has added the recommended additional verbiage to ensure there is a mutual understanding between licensing and TRELS Home Staff.


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

raw_content: 4 of 4 admission's assessment's did not include the child's history of other placements.

Correction Narrative: TRELS Home For children has added the missing section in Extended Reach. TRELS recently switched to extended reach, the programming department missed transferring this section. It has been added.


raw_content: 2 of 4 placement agreements were not completely filled out.

Correction Narrative: TRELS Home For Children will add an additional placements agreement into extended reach so if the check boxes are missed on one document they will be caught on the 2nd. TRELS Missed that the caseworker did not mark the boxes on the 2 siblings that were audited.


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

raw_content: 3 of 3 records reviewed were missing added information regarding the child's birth/neonatal history; and known contraindications to the use of restraints. 2 of 3 records reviewed were missing previous placement and school history information.

Correction Narrative:
TRELS Home For Children PLSP will email caseworkers to ensure birth and neonatal history is added to the child's file.

TRELS Home for Children has updated the admissions assessment to ensure the line for contraindications of restraints is not cut off during the printing process.  It is to be noted that the answer to the question is on the electronic version of the form but not on the printed version.

TRELS Home for Children has updated the admission assessments with school and previous placement history.


facility_name: Adore Living Child Services Inc.

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: Backgrounds reviewed found a person was not inactivated timely.


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

raw_content: In reviewing one of the staff charts there was nothing to validate that the references were verified before hiring.

Correction Narrative:
We have audited all new employee folders to ensure that references were checked and documented.
In the future, a check list will be in front of each employee's folder with a check list to make sure this process is complete. If we are not able to contact the reference, the date and time we attempted to contact references will be notated.


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

raw_content: In reviewing charts it was found 2 of 2 charts were missing required information in the staff charts such as hire dates and  current job descriptions.

Correction Narrative:
To ensure staff folders are in compliance, we will follow the check list provided in the front of the employee's folder. Each position will have a job description to for a clear understanding of work expectations. We will conduct monthly audits on the employee folders consistent with auditing the binders to prevent missing dates and documentation.
We will create a two-tier system that requires the supervision and administrator's signatures once the folders are audited.


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

raw_content: In reviewing staff charts it was determined a staff is emploed and working with children over the age of 13 but will not be 21 years old until June.

Correction Narrative:
The current population in our facility is 13 yrs. or older.  The employee in question is now 21 yrs. of age therefore the deficiency has been corrected.
In the future, if we hire an employee that is not 21 or older, we will pair that employee with another employee 21 and above, to ensure that this will not happen again.


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

raw_content: During the course of this investigation, multiple children indicated that they were left alone at the operation for up to 20 minutes.

Correction Narrative: Staff was terminated. Background check validated worker was no longer had an active background check. Current employee list did not have the staff. Program Coordinator conducts random checks to supervise staff and ensure compliance.


summary: 748.125(f)(2)(B) - Post hospitalization protocols must include creating or reviewing and updating the childs safety plan.

raw_content: Knowing that the child in care self-harmed, has a history of high-risk behaviors and had just returned back to the Operation's care from receiving mental health intervention after self-inflicting, there was no safety plan implemented upon child's return to ensure risk of further self-harming was mitigated.

Correction Narrative: The operation did not take the child back into their care, as they did not feel they could meet their needs.  In response to the deficiency received concerning standard 748.125 ( f ) (2 ) ( B ), Post hospitalization protocols must include creating or reviewing and updating the child's safety plan. Moving forward Adore Living will request a discharge staff meeting prior to youth returning. This meeting will require updates on the hospitalization stay and any recommendations concerning the discharge from medical professionals. `We will review the youth's safety plan and make any adjustments as needed. This process will prevent any delays in updating the child's safety plan or assessments. Please let us know if you have further recommendations for us. It is always our goal to keep our youth safe.


summary: 748.3115(3) - Fire Extinguisher-Must ensure fire extinguishers are serviced as required by manufacturer's instructions, or as required by fire inspector

raw_content: In conducting the walk it was observed the fire extinguisher was last inspected 11/21 and had expired.

Correction Narrative: An in person was conducted and the fire extinguisher is now in compliance. Pictures were taken.


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

raw_content: 3 Child charts were reviewed and required documentation was missing.

Correction Narrative: Due to Adore Living not using restraints, they will discuss alternatives with the caseworker at time of admission and document in the chart. MLayton


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

raw_content: Out of 3 child charts reviewed, none had documentation to show what date the orientation occurred.

Correction Narrative: Received email from Sandra Williams stating going forward they will have all parties sign and date when orientation is complete. MLayton


raw_content: Operation staff admitted to letting child in care have cigarette and leaving their lighter on the counter in the reach of child in care.

Standard Number / Description: 748.1661(a) - Tobacco Products and E-Cigarettes -Children may not use or possess tobacco products, e-cigarettes or any type of vaporizers

Correction Narrative:
	We will retrain staff on this standard and make sure that all smoking devices are not allowed at the facility.
	We will reiterate the importance of good decision making and the consequences that will occur should unacceptable choices be made.
	We will reemphasize that Adore Living is a tobacco free environment and we have zero tolerance with this policy.


raw_content: During the course of the investigation staff was in the office allowing the child to be out of eyesight and gain access to another child and assault them.

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

Correction Narrative: Staff will evaluate if more staff are needed in the future.


summary: 748.1271(6) - Emergency Admission Documentation-Identification of child's high risk behaviors and related safety plan staff and caregivers will implement

raw_content: During the course of the investigation it was found documentation given at the time of intake revealed the child had high risk behaviors and a Safety Plan was not put into place.

Correction Narrative: Received email from Sandra Williams stating the staff have been spoken with and in the future behaviors will be addressed by reading the Common App and asking CPS.


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

raw_content: The operation has two total First-Aid kits. Both FIrst-Aid kits did not contain a thermometer, tweezers or scissors.


facility_name: Fort Behavioral Health

summary: 748.158(1) - Operational Responsibilities- Maintain liability insurance coverage in the amount of $300,000 for each occurrence of negligence

raw_content: Liability Insurance is expired. Operation did not provide updated documentation.

Correction Narrative: The operation submitted documentation for liability insurance.


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

raw_content: Operation health inspection was not completed 12 months from the last inspection. The last health inspection was completed 10/23/2023.

Correction Narrative: On 7/8/2025, RCCR received a sanitation inspection completed at the operation. On 7/15/2025, technical assistance was provided during inspection #4065969 recommending the operation completes a sanitation inspection that incorporates the entire living and common spaces used for potential clients in care. The sanitation inspection is uploaded to the document library.


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

raw_content: 2 of 2 child files reviewed did not indicate signatures from the children being admitted. During a follow up inspection on 12/8/2023, no documentation was received to support compliance for this standard due to administrators not being available. One admin was on leave and the other attending a family emergency.

Correction Narrative: On 12/12/2023 RCCR received a child rights template from LCCA with a section for children to sign for future use.


raw_content: 2 of 2 child files reviewed did not indicate signatures from the children being admitted.

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

Category: Children's Rights


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

raw_content: 2 of 4 employee files does not include job description for current job title.

Correction Narrative: The case files were reviewed during November's monitoring inspection and was in compliance.


raw_content: 2 of 4 employee files did not include date of employment.

Standard Number / Description: 748.363(1) - Personnel records-Include date of employment


summary: 748.561(1) - Responsibilities of Professional level service provider-Completing an admission assessment or any other evaluation of a child for placement

raw_content: A person who signed the admission assessment admitted to not conducting it.

Correction Narrative:
The following compliance plan was submitted by the operation: It is against our policy for staff to sign a document that they did not complete. The previous Director of Admissions has since been terminated and it was reiterated with all admission staff to only sign documents they attest to have completed. Also, in order to better document who did the assessment versus who did the MSE when the patient arrives, after an intake coordinator does a virtual assessment, they will leave the document open for the person completing the MSE to sign. Whoever completes the MSE upon pt arrival, will sign the assessment and add an annotation to the bottom of the assessment stating "Assessment completed by ________. MSE completed by  ________. However, intake will recommend in-person assessments so this isn't an issue at all.
The operation's persons list was observed to not have an director of admissions hired.


summary: 748.1437(7) - Discharge/Transfer Documentation-For emergency discharge/transfer, document reason for discharge/transfer explained to child, and child's reaction

raw_content: Discharge summary does not include child's reaction to discharge.

Correction Narrative:
On 11/21/2023 RCCR recieved a compliance plan stating the operation will include a section in the discharge summary to document children's reactions.
During a follow-up inspection on 12/8/23, proof of template was requested but not provided due to administrator's taking leave and a family emergency. It was discussed the templates can be sent via email.

On 12/13/2023 a template was received of discharge summary. RCCR observed a section in the discharge summary to document child's reaction to discharge.
RCCR received a discharge summary template with


summary: 745.8641 - Requirements during probation

raw_content:
Condition #1 - Met

Condition #2 - Met

Condition #3 - Met

Condition #4 - Met

Condition #5 - Met

Condition #6 - Met

Condition #7 - Met

Condition #8 - Met

Condition #9 - Met

Condition #10 - Met

Condition #11 - Not Met

Condition #12 - Met

Condition #13 - Met

Condition #14 - Met

Condition #15 - Met

Correction Narrative: Documentation was received with follow-up discussion with staff member.


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: Medication log pill count shows a child was given more medication than instructed.

Correction Narrative: 4  medication logs were reviewed to meet compliance while the operation's electronic system is down.


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 was out of ratio when a unit of 11 children were left in the care of 2 caregivers, when 3 caregivers were required.  One child was indicated to be on one-on-one supervision.  The Administrator did not ensure the operation had sufficient staff to care for children in care.

An acting administrator left the facility and did not provide a plan to mitigate risk to children while the unit was out of ratio.

Correction Narrative: extension granted due to AR.  On 3/20/2024, the operation submitted the following plan related to the citation via email:All administrators receive the weekly staffing schedule. However, it was not related to the administrator that some staff did not show up for their shifts and therefore units were short staffed. Should the administrator been made aware, they would have joined the unit to be included in ratio. Staff will be reminded to contact the administrator for extra support. On 8/14/2024, during an inspection RCCR Inspector observed no children or staff members present at the operation.


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: The operation was out of ratio when two caregivers were left to care for 11 children.  The operation continued to be out of ratio when one caregiver was left to care for ten children.

Correction Narrative: On 3/20/2024, the operation submitted the following plan related to the citation via email: Staff will be reminded of the standard ratio of 1-5 and the process to request additional help if ratio is not met, including radioing for support or calling the acting administrator. On 8/14/2024, during an inspection RCCR Inspector observed no children or staff members present at the operation.


summary: 748.685(c)(2) - Caregiver responsibility - provide a safe environment

raw_content: Caregivers did not provide appropriate supervision and environment to children when an acting administrator and supervisor on duty left one caregiver to care for 10 children.  Children in care engaged in a physical altercation and the single caregiver was unable to de-escalate the physical altercation and ensure child safety.  As a result, one child sustained a significant physical injury. The ratio required at the time of the incident was to be 1 caregiver to every 5 children.

Correction Narrative: extension granted due to AR. On 3/20/2024, the operation submitted the following plan related to the citation via email: Staff will be reminded of the standard ratio of 1-5 and the process to request additional help if ratio is not met, including radioing for support or calling the acting administrator. On 8/14/2024, during the inspection RCCR Inspector observed no children or staff members present at the operation.


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

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

Correction Narrative: extension granted due to AR.  On 3/20/2024, the operation submitted the following plan related to the citation via email: Staff will be reminded of the standard ratio of 1-5 and the process to request additional help if ratio is not met, including radioing for support or calling the acting administrator. On 8/14/2024, during the inspection RCCR Inspector observed no children or staff members present at the operation.


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

raw_content: At 17:30, after being injured, a child was observed to bleed from the eye, enough to soak a shirt and cover the floor.  The operation did not contact EMS until 17:50

Correction Narrative: extension granted due to AR. On 8/22/2024 RCCR made phone contact with the operation. It was discussed that in the event the Nurse is the health care professional at the operation. When a child is in need of medical treatment, a code is called for the nurse to respond to the child in need. After the nurse makes an assessment of the child and it determined the child needs EMS, EMS will be called at that time. On 8/14/2024, RCCR Inspector observed no children or staff members present at the operation.


raw_content:
Condition #1: Progress reviews for the improvement plan were not available for review.

Condition #12: Changes to the personnel file audit were not observed or that the personnel file was still missing the job description, person responsible for the changes, due date, and correction date.

Correction Narrative: RCCR received a personnel audit file on 9/15/2023 with the appropriate change to audit form. RCCR observed biweekly improvement plan progress report during 9/26/23 inspection.


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

raw_content: Child in care, with history of self-harming, continue to cut and scratched herself.

Correction Narrative: There are no caregivers or children currently at the operation.


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

raw_content: 4 of 6 child files reviewed had preliminary service plans that were signed outside of 72 hours.

Correction Narrative: 4 child files were observed to be signed within 72hrs.


raw_content:
Condition #1 - Does not meet
Condition #2 - Met
Condition #3 - Met
Condition #4 - Met
Condition #5 - Met
Condition #6 - Met
Condition #7 - Met
Condition #8 - Met
Condition #9 - Met
Condition #10 - Met
Condition #11 - Met
Condition #12 - Does Not  Meet
Condition #13 - Met
Condition #14 - Met
Condition #15 - Met


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

raw_content: 2 of 6 employee files reviewed had suicide prevention training that did not include the number of training hours on the certificates.

Correction Narrative: 2 employee training files were reviewed to have training hours.


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

raw_content: Policy and procedures require that only an LVN, RN or medication aide administered medication to children in care. This procedure was not followed.


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

raw_content: Non-prescription medication provided to a child in care was not documented on the medication log.


summary: 748.2855(a)(4) - EBI Documentation-Must include the specific emergency behavior intervention administered

raw_content: Incident report does not indicate a restraint was used.


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

raw_content: A caregiver failed to provide appropriate supervision which allowed two children to engage in inappropriate contact while on duty at the operation.

Correction Narrative:
RCCR received the following compliance plan from the operation. There are currently no children in care: All staff will be retrained on supervision and the importance of being involved with the youth.  Also, each staff will have to read the service plans of each youth before going on the unit to work their shift.  A lead or Manager will review to make sure the staff has read the service plan before being allowed to work on the unit for there shift.

During probation inspection on 11/17/2023, it was noted that no direct care staff members are present and no children placed at the operation. At this time the operation does not have staff members to train on supervision.


summary: 748.1331(f) - Preliminary Service Plan-Implement and follow the preliminary service plan

raw_content: Two children at the operation were not supervised in accordance with the information that is described and documented in each child' s individual service plan.

Correction Narrative:
RCCR received the following compliance plan from the operation. There are no children currently in care: The service plan will be read by each staff upon arrival of their shift. All staff will have to read the service plan of each child before being allowed on the Unit to work their shift.  All staff will have to initial that they have read and understand the service plan for each youth.  A lead or Manager will review to make sure the staff has read the service plan before being allowed to work on the unit for there shift.

During probation inspection on 11/17/2023, it was noted that no direct care staff members are present and no children placed at the operation. At this time the operation does not have staff members to train on supervision.


raw_content: Two children in care (15 and 17 years of age) were involved in inappropriate sexualized behavior while placed at the operation, and the caregiver was unaware of the children's activity.

Correction Narrative:
RCCR received the following compliance plan from the operation. There are no children in care currently: We will increase supervision and retrain staff on supervision and the importance of supervision.  We will also make sure there is a lead and manager floating each unit to make sure supervision is being done correctly at all times.

During probation inspection on 11/17/2023, it was noted that no direct care staff members are present and no children placed at the operation. At this time the operation does not have staff members to train on supervision.


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

raw_content: There was a toilet that was clogged and was not in working order.


raw_content: Serious incident report does not indicate the specific emergency behavior technique.

Standard Number / Description: 748.2855(a)(4) - EBI Documentation-Must include the specific emergency behavior intervention administered

Correction Narrative: RCCR received the following compliance plan from the operation. Children are no longer in care: All children have been discharged from the facility. Prior to readmitting any children, we will review the documentation for EBIs and ensure that it requires staff to select whether a personal restraint or short personal restraint was used on the child. If a personal restraint was used, staff will be required to select what type of SAMA restraint it was.


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

raw_content: Children in care were allowed to remain in the same proximity when children were restrained, which resulted in a restrained child being kicked.

Correction Narrative: RCCR received the following compliance plan. There are no children currently in care: All children have been discharged from the facility. Prior to readmitting any children, staff will be trained to remove child witnesses from emergency situations to prevent accidental injury and to protect the privacy of the child in distress.


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

raw_content: 2 of 5 employee files did not have documentation of education.


summary: 748.1225(b) - Admission-Dental exam for child 3 years old or older scheduled in 30 days and done in 90 days unless documentation of one within past year on file

raw_content: 5 of 5 child files did not have dental visit scheduled.


summary: 745.8641 - Requirements during probation

raw_content:
Condition #1: Met
Condition #2: Met
Condition #3: Not Met - 11 out of 30 employees hired or rehired did not have a comprehensive assessement.
Condition #4: Met
Condition #5: Met
Condition #6: Met
Condition #7: Met
Condition #8: Met
Condition #9: Met
Condition #10: Met
Condition #11: Met
Condition #12: Met
Condition #13: Not Met - 5 of 5 service plans audits were missing required documentation.
Condition #14: Met
Condition #15: Met


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

raw_content: 5 of 5 child files did not have immunization records.


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: 5 of 5 child files reviewed did not have TB test results. 1 of 5 employee files did not have TB test results.


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: Abuse/Neglect investigation reported two staff members did not provide adequate medical care for a child in care.

Correction Narrative: During an inspection it was found that the employees involved are no longer working in the adolescent programs.


summary: 748.1331(b)(3) - Preliminary Service Plan-For child receiving treatment services, include description of how operation will meet child's needs

raw_content: Childs preliminary service plan does not describe how the operation will meet the childs medical needs or follow-up plan for possible side effects.

Correction Narrative:
The operation sent a compliance plan stating they will exclude admissions for children with a history of Severe psychiatric disorders including psychosis, severe clinical depression that includes active suicidal ideation with plan.
Chronic predisposition to destructive, aggressive and violent behavior incompatible with a group living environment. Acute, chronic medical conditions requiring constant medical attention. Incontinence or inability to perform ADLs without assistance. The following requires medical approval before admission: Oxygen requirement, Diabetes-requires write up of home protocol from patient's provider, COPD, Cirrhosis and History of heart attack.


summary: 748.2053 - Medication Self-Administration-The child must record dosage or report medication to an employee who records the dosage daily

raw_content: Record for daily insulin dosages were not documented in the medication log

Correction Narrative: The operation sent a compliance plan stating they will exclude admissions for children with a history of Severe psychiatric disorders including psychosis, severe clinical depression that includes active suicidal ideation with plan. Chronic predisposition to destructive, aggressive and violent behavior incompatible with a group living environment. Acute, chronic medical conditions requiring constant medical attention. Incontinence or inability to perform ADLs without assistance. The following requires medical approval before admission: Oxygen requirement, Diabetes-requires write up of home protocol from patient's provider, COPD, Cirrhosis and History of heart attack.


summary: 748.2051(2) - Medication Self-Administration-Self-medication program must be in the child's service plan & include requirements for caregiver supervision

raw_content: Childs preliminary service plan did not include self medication protocols for child and staff members to ensure the childs health and safety.


summary: 748.1437(2) - Discharge/Transfer Documentation-Must include date and time the child was informed of his discharge or transfer

raw_content: Discharge documentation did not discuss when the child was informed of discharge or transfer.

Correction Narrative: Treatment Director created an acknowledgement form for each of the therapists to sign reviewing the process of completing the DC Summary. The DC Summary specifically includes questions regarding when the child was notified, their reaction, etc. These acknowledgment forms will be placed in the therapist's HR files by Friday, 9/1 for state review if needed. Any additional violations with not entering the required information will result in disciplinary actions for the employee.


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: One caregiver was responsible for eight children when a physical altercation broke out between two children in care.

Correction Narrative:
RCCR received the following compliance plan: The operation added a section on the staff assignment sheet to include which children are assigned to which staff. Staff will have to initial the assignment sheet at the beginning of their shift. These assignment sheets will be turned into the CC Manager and stored for review if needed. See example attached.

A follow up inspection was completed on 8/17/2023. During the inspection Resident Assignment documents were observed. Staff members are documenting which children they are responsible for each shift.


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

raw_content: An employee is present at the operation with an inactive background check status.

Correction Narrative: Background checks were reviewed and verified to be active.


summary: 748.2003(b)(6) - Administration of prescription medication-ensure a person trained in & authorized to administer prescription medication administers the medication

raw_content: Employee who has not completed medication administration training has given medication to a child in care.

Correction Narrative: The purpose of this rule is to prevent harm to children due to inappropriate storage, preparation, or administration of medications. It is recommended that only the employees who have finished orientation and shadowing are documented as administrating medication.


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

raw_content: 4 of 4 medication logs were missing the medication pill count.

Correction Narrative: All medication logs reviewed, and all logs included the remaining pill count.


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

raw_content: 4 of 4 mediaction files were missing prescribing health-care professional's name as well as reason for medication.

Correction Narrative: All medication logs were reviewed. All medication logs included the health care professional's name.


raw_content:
Condition # 1: Pending - extention granted to 7/10/23.
Condition #2: Met
Condition #3: Not Met - operation did not complete a new comprehensive assessment for a rehired employee
Condition #4: Met
Condition #5: Met
Condition #6: Not Met - Employee administered medication before completing medication training requirement per the condition
Condition #7: Met
Condition #8: Met
Condition #9: Met
Condition #10: Met
Condition #11: Met
Condition #12: Met
Condition #13: Not Met - Operation is not completing audit of child files at admission. The operation is not completing audit of children files per the requirement of this condition.
Condition #14: Met
Condition #15: Not Met - operation did not provide documentation to RCCI in a timely manner. This is in reference to INV#49478617.

Correction Narrative:
Condition # 1: Meets condition requirement.
Condition #2: Met
Condition #3: Pending review until next probation inspection - operation did not complete a new comprehensive assessment for a rehired employee
Condition #4: Met
Condition #5: Met
Condition #6: Met
Condition #7: Met
Condition #8: Met
Condition #9: Met
Condition #10: Met
Condition #11: Met
Condition #12: Met
Condition #13: Pending review until next probation inspection - Operation is not completing audit of child files at admission. The operation is not completing audit of children files per the requirement of this condition.
Condition #14: Met
Condition #15: Pending review until next probation inspection - operation did not provide documentation to RCCI in a timely manner. This is in reference to INV#49478617.


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: 3 of 4 child files reviewed had missing medication dosages.

Correction Narrative: All child medication logs were reviewed. All medications included the medication dosages.


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

raw_content: On June 13th a child was provided a mental health assessment due to a suicide attempt.  The child was then hospitalized for treatment. The incident was not reported to Licensing until 3 days later. The incident was not documented as a serious incident.


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

raw_content: The operation documents a serious incident report as a incident report.

Correction Narrative:
The operation developed a job aide to help staff determine the difference between suicidal gesture versus suicide attempt. This will be distributed via TEAMS, posted in the staff offices, and handed out at the next staff meeting. During the inspection it was communicated the next staff meeting is 9/20/23. An extension was granted 9/20/23 to ensure the operation implements the provided plan including notifying caregivers during staff meeting.

An inspection was conducted on 9/26/23. During the inspection a serious incident report resulting in an injury to a child was reviewed. The documentation describes a staff member attempted intervention which included body positioning, verbal redirections for children and calling the assistance of other staff members.


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

raw_content: A child in care was left unsupervised during a one-on-one supervision resulting in suicide attempt.

Correction Narrative:
RCCR received a compliance plan stating staff will be reminded of duties of a 1:1 via job aide that will be distributed during the next staffing meeting. A graphic was shared with RCCR stating one on one reminders for staff members. A follow-up inspection is scheduled for 9/13/23.

During the inspection on 9/13/23 an extension was granted to the operation. The purpose of the extension is to allow the operation to complete 1 to 1 job aide during a monthly "Townhall meeting". Monthly meetings with staff members to evaluate inspection and investigation findings is a conditional requirement during the operation's probation. An LCCA of the operation communicated the meeting is scheduled for 9/20/23. The extension is until 9/20/23.

On 9/26/23, during the probation inspection RCCR spoke with 4 staff members related to the difference between suicide attempt and gesture as well as 1 to 1 supervision strategies.


summary: 748.303(a)(12)(B) - Serious Incident-Report to parents immediately after ensuring the safety of the child any suicide attempt by their child.

raw_content: A child in care attempted suicide and the operation did not document the how the parent was notified.

Correction Narrative: RCCR was provided with documentation stating a parent was notified of suicide attempt by a caregiver.


summary: 748.125(e)(2)(E) - You must adhere to recommendations of the MH professional and update the childs safety/service plan's if child is a potential risk for suicide.

raw_content: In reviewing the admission assessment, youth-in-care assessment of suicide potential was high and intervention plan was not properly implemented.

Correction Narrative:
RCCR received an updated safety plan for compliance. In the safety plan the following information was included:
Behaviors that warrant increased supervision was explained. Supervision level was moved to 1 to 1 during wake hours and 5 minute checks during sleep hours. The child's physical environment was restricted per these instructions.
       Finger foods only to limit access to utensils.
	Safety linens: Removal of all bed sheets and client is given 2 comforters.
	Unit Restriction: Client cannot leave the unit except for school.
	Visitation Restriction: Client cannot have in-person visitation.
	Room Search: Doctors order must be obtained
	Body Search: Doctors order must be obtained
	Other: _______________________________


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: Youth-in-care did not receive a new Suicide Full Assessment when admitted to care.

Correction Narrative:
The safety assessment form was completed according to minimum standards rule. Updates require additional monitoring for safety.
RCCR received an updated safety plan for compliance. In the safety plan the following information was included:
Behaviors that warrant increased supervision was explained. Supervision level was moved to 1 to 1 during wake hours and 5 minute checks during sleep hours. The child's physical environment was restricted per these instructions.
       Finger foods only to limit access to utensils.
	Safety linens: Removal of all bed sheets and client is given 2 comforters.
	Unit Restriction: Client cannot leave the unit except for school.
	Visitation Restriction: Client cannot have in-person visitation.
	Room Search: Doctors order must be obtained
	Body Search: Doctors order must be obtained
	Other: _______________________________


summary: 748.2001(b) - Administration of Medication-Must obtain written, signed, & dated consent for a new psychotropic medication

raw_content: 3 medication files were observed to not have legal guardian signature for psychotrophic medication consent.

Correction Narrative: All child files were observed to have psychotrophic medication consent forms signed by guardians.


summary: 745.8641 - Requirements during probation

raw_content:
Condition #1: The program evaluation submitted is a check list, that provides rating of each criterion. It does not provide information to the reader on how each determination was made.
Condition #2: Met
Condition #3: Met
Condition #4: Met
Condition #5: Met
Condition #6: Medication policies state a specified person will administer medication, medication file was observed to have multiple nurses administer medication to a child in care.
Condition #7: Met
Condition #8: Met
Condition #9: Met
Condition #10: Met
Condition #11: Met
Condition #12: Met
Condition #13:This condition is considered not met because the date of correction is not being documented on the audit form.
Condition #14: Met
Condition #15: Met


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

raw_content: Treatment plans indicated that children must be observed every 15 minutes by staff members. These instructions were not followed.

Correction Narrative:
Girls unit was move to have one child to a bedroom, the jack and jill bathrooms will no longer be of concern.
2. Staff members are instructed to sit in the middle of the hallways to supervise children.
3. A Manager and Lead will be on duty 24 hours a day. The Manager and lead are walking the hall ways to ensure staff are doing what they are asked to do.
4. A performance plan was implemented that will explain any rule violation to a staff member one time and then if violated again that staff member will be terminated.
In addition on 06/26/23 the operation submitted the following ongoing plan:
We are conducting weekly audits of rounding documentation where we audit 3 periods of time via cameras to ensure staff are monitoring children appropriately and documenting in their charts correctly.
We are adding a Care Coordinator Lead to each shift on each unit that is not counted in ratio but is available for general oversight, and staff breaks. This includes having a Lead overnight to float to each unit for floor checks.
An LCCA will also have live video footage playing throughout the business day to help with general oversight while another LCCA rounds on the units.


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

raw_content: During sleeping hours, a child in care entered multiple rooms several times without staff's knowledge.

Correction Narrative:
Girls unit was move to have one child to a bedroom, the jack and jill bathrooms will no longer be of concern.
2. Staff members are instructed to sit in the middle of the hallways to supervise children.
3. A Manager and Lead will be on duty 24 hours a day. The Manager and lead are walking the hall ways to ensure staff are doing what they are asked to do.
4. A performance plan was implemented that will explain any rule violation to a staff member one time and then if violated again that staff member will be terminated.
In addition on 06/26/23 the operation submitted the following on going plan:
The operation will conduct weekly audits of rounding documentation where they audit 3 periods of time via cameras to ensure staff are monitoring children appropriately and documenting in their charts correctly. Should a staff member not follow the service plan/policy of Fort Behavioral, they may be placed on a Performance Improvement Plan (PIP), have disciplinary action taken, or be terminated.


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

raw_content: Clinical Progress Logs documents that children were observed by staff members when they were not.

Correction Narrative:
Girls unit was move to have one child to a bedroom, the jack and jill bathrooms will no longer be of concern.
2. Staff members are instructed to sit in the middle of the hallways to supervise children.
3. A Manager and Lead will be on duty 24 hours a day. The Manager and lead are walking the hall ways to ensure staff are doing what they are asked to do.
4. A performance plan was implemented that will explain any rule violation to a staff member one time and then if violated again that staff member will be terminated. On 06/26/23 the operation submitted an ongoing plan explaining We are conducting weekly audits of rounding documentation where we audit 3 periods of time via cameras to ensure staff are monitoring children appropriately and documenting in their charts correctly. Should a staff member not follow the service plan/policy of Fort Behavioral, they may be placed on a Performance Improvement Plan (PIP), have disciplinary action taken, or be terminated.


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

raw_content: 2 service plans reviewed were not completed in 72 hours.


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

raw_content: The operation failed to notify Licensing within 24 hours of a child in care being transported by EMS for emergent medical care.

Correction Narrative:
On June 26, 2023, RCCR received a compliance plan from the operation in response to the deficiencies cited.  The compliance plan indicates the operation has retrained all staff regarding serious incident reporting and implemented a step by step process for ensuring staff have guidance for measures that need to be taken during and after an incident.  All staff have signed acknowledgement of the updated process.  Compliance with this plan will be assessed in a follow-up inspection.

A follow-up inspection was completed on 7/11/2023. During the inspection incident report acknowledgement forms were observed for 71 of 72 staff members.


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

raw_content: An incident report completed five days after the incident occurred did not include a description of the incident.

Correction Narrative:
On June 26, 2023, RCCR received a compliance plan from the operation in response to the deficiencies cited.  The compliance plan indicates the operation has developed a committee to review all incident reports for documentation criteria and timeliness.  Compliance with this plan will be assessed in a follow-up inspection.

On July 11, 2023, RCCR completed a follow-up inspection. During the inspection 2 serious incident reports were reviewed. The serious incident reports included a description of the incidents that took place.


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

raw_content: A restraint that lasted 3 to 5 minutes was not documented.


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

Deficiency Narrative: 2 service plans reviewed were not completed in 72 hours.


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

raw_content: 3  medication logs  show medication was taken without a stated reason.

Correction Narrative: Reason for medication being administered was observed on medication log


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

raw_content: 5 Medication logs did not have prescribing doctor listed.


raw_content:
5 out 15 probation conditions were not met.

Condition #1: Met
Condition #2: Met
Condition #3: Met
Condition #4: Met
Condition #5: Met
Condition #6: Met
Condition #7: the training was not due per conditions.
Condition #8: Did not meet - trainings not completed with all staff by the due date of 4/12/2023;
Condition #9: Did not meet - 18 staff members did not complete trainings by 03/26/2023;
Condition #10: Did not meet - 13 staff members trainings were not completed by 3/26/2023;
Condition #11: Met
Condition #12: Met
Condition #13: Met
Condition #14: Did not meet - one child file did not have parent notification;
Condition #15: Met


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

raw_content: 5 Medication logs did not have a pill count or inventory listed.


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

raw_content: A child's suicide attempt was not reported as required by minimum standards.

Correction Narrative:
During the inspection it was discussed staff members are being trained on when to report a serious incident versus when to document a minor incident. Posts were observed in the units describing what needs to be reported to CCR.

All suicide attempts are deemed as urgent and accessed as priory level one (1) at Fort Behavioral Health with the following actions taken:
	The client is immediately placed with a staff on duty, avoiding any addition attempts to self- harm. The assigned staff remains with the client, ensuring safety and supervision.
	Medical Assessment (conducted by the nurse on duty).
	A Columbia Assessment is conducted (All Staff is trained to conduct the assessment). The Columbia Assessment is located under the Clinical Assessment in KIPU.
	Room search, ensuring there are no items hidden or self-made that can be utilized to carry out a plan to self-harmroom is deemed and reported as safe prior to the client returning.
	Hotline Call /Report For ALL SUICIDE ATTEMPTS, which will state the date / time of the calls, Name and ID # from Intake / Report number, all of which is documented in the clients file / chart in KIPU.
	Notification to the guardian listed on file, located in KIPU.
	Notification to the therapist regarding a client follow-up.
	Continuous Care: The advised (doctors) orders are followed ensuring that safety and supervision is met.
	 Continuous Care: After the Clinical Assessments or /and changes in the Doctors Orders (if required) the client remains on Close Monitored Supervision.
	Continuous Care: All Managers / Leads are required to conduct a walkthrough before and after each shiftNotification required.
Safety Plans:
	All Safety Plans are and will be adjusted throughout the stay of each client until discharged (d/c) from the facility, which include doctor's orders and changes that range as followed: q5, q15, and 1:1 supervision.
Orders that indicate 1:1 during wake hours, the sleep hours consist of staff positioned at the doorway of clients assigned sleeping area, ensuring that safety and supervision is carried outThis method can be advised by the LCCA, or and the AOC (Administrator On Call).
Method of Communication:
	The notification and communication methods of these changes are provided to the staff employed at Fort Behavioral Health include both via Teams and Shift Reports, as well as a DIRECT ORDER (documented) from Administration, ensuring that the proper rounds are being conducted for the safety of the client.

In closing, Fort Behavioral Health will continue to conduct the required trainings to all staff working with clients that are in care / treatment until discharged, ensuring that safety and supervision is provided under the rules of Minimum Standards. In addition, staff will continue to conduct rounds that are set forth or / and recommend within the Safety Plan, catering to needs of each client and made aware of any / all changes.
All staff will continue to be briefed on the history and made aware of all precautionary measures recommended upon intake, as well as a review / refresher on trauma and triggers during shift reports.
Fort Behavioral Health with continue to supervise, monitor, review, and train each staff placed on a Performance Improvement Plan (PIP), ensuring that the conditions are met under the rules and guidelines for Minimum Standards.
Fort Behavioral Health will continue to improve with great efforts with a Continuous Plan of Care for each client, adhering to Policy changes under the rules and guidelines for Minimum Standards.


raw_content: A caregiver failed to abide by a child's supervision requirements which resulted in a suicide attempt.

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

Correction Narrative:
During follow-up inspection on 6/16/23. It was discussed that the staff member cited during the investigation no longer works at the operation. This was verified through the operation's peoples list.
The following information was sent via email as a response to the citations.
All suicide attempts are deemed as urgent and accessed as priory level one (1) at Fort Behavioral Health with the following actions taken:
	The client is immediately placed with a staff on duty, avoiding any addition attempts to self- harm. The assigned staff remains with the client, ensuring safety and supervision.
	Medical Assessment (conducted by the nurse on duty).
	A Columbia Assessment is conducted (All Staff is trained to conduct the assessment). The Columbia Assessment is located under the Clinical Assessment in KIPU.
	Room search, ensuring there are no items hidden or self-made that can be utilized to carry out a plan to self-harmroom is deemed and reported as safe prior to the client returning.
	Hotline Call /Report For ALL SUICIDE ATTEMPTS, which will state the date / time of the calls, Name and ID # from Intake / Report number, all of which is documented in the clients file / chart in KIPU.
	Notification to the guardian listed on file, located in KIPU.
	Notification to the therapist regarding a client follow-up.
	Continuous Care: The advised (doctors) orders are followed ensuring that safety and supervision is met.
	 Continuous Care: After the Clinical Assessments or /and changes in the Doctors Orders (if required) the client remains on Close Monitored Supervision.
	Continuous Care: All Managers / Leads are required to conduct a walkthrough before and after each shiftNotification required.
Safety Plans:
	All Safety Plans are and will be adjusted throughout the stay of each client until discharged (d/c) from the facility, which include doctor's orders and changes that range as followed: q5, q15, and 1:1 supervision.
Orders that indicate 1:1 during wake hours, the sleep hours consist of staff positioned at the doorway of clients assigned sleeping area, ensuring that safety and supervision is carried outThis method can be advised by the LCCA, or and the AOC (Administrator On Call).
Method of Communication:
	The notification and communication methods of these changes are provided to the staff employed at Fort Behavioral Health include both via Teams and Shift Reports, as well as a DIRECT ORDER (documented) from Administration, ensuring that the proper rounds are being conducted for the safety of the client.

In closing, Fort Behavioral Health will continue to conduct the required trainings to all staff working with clients that are in care / treatment until discharged, ensuring that safety and supervision is provided under the rules of Minimum Standards. In addition, staff will continue to conduct rounds that are set forth or / and recommend within the Safety Plan, catering to needs of each client and made aware of any / all changes.
All staff will continue to be briefed on the history and made aware of all precautionary measures recommended upon intake, as well as a review / refresher on trauma and triggers during shift reports.
Fort Behavioral Health with continue to supervise, monitor, review, and train each staff placed on a Performance Improvement Plan (PIP), ensuring that the conditions are met under the rules and guidelines for Minimum Standards.
Fort Behavioral Health will continue to improve with great efforts with a Continuous Plan of Care for each client, adhering to Policy changes under the rules and guidelines for Minimum Standards.


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

raw_content: A child placed a bag over the head with the intent to harm himself. The child was not properly assessed for safety after this incident by the operation as required by Minimum Standards.

Correction Narrative:
During the inspection on 6/16/23, it was discussed that all employees receive training on the suicide screening. If a child exhibits suicidal behaviors the child will be placed on 1 on 1 supervision until approved by doctor's orders to change supervision protocols. The child will receive another assessment in 72- hours. The staff member involved is no longer working at the operation.

The following information was submitted as a response to the citation:

All suicide attempts are deemed as urgent and accessed as priory level one (1) at Fort Behavioral Health with the following actions taken:
	The client is immediately placed with a staff on duty, avoiding any addition attempts to self- harm. The assigned staff remains with the client, ensuring safety and supervision.
	Medical Assessment (conducted by the nurse on duty).
	A Columbia Assessment is conducted (All Staff is trained to conduct the assessment). The Columbia Assessment is located under the Clinical Assessment in KIPU.
	Room search, ensuring there are no items hidden or self-made that can be utilized to carry out a plan to self-harmroom is deemed and reported as safe prior to the client returning.
	Hotline Call /Report For ALL SUICIDE ATTEMPTS, which will state the date / time of the calls, Name and ID # from Intake / Report number, all of which is documented in the clients file / chart in KIPU.
	Notification to the guardian listed on file, located in KIPU.
	Notification to the therapist regarding a client follow-up.
	Continuous Care: The advised (doctors) orders are followed ensuring that safety and supervision is met.
	 Continuous Care: After the Clinical Assessments or /and changes in the Doctors Orders (if required) the client remains on Close Monitored Supervision.
	Continuous Care: All Managers / Leads are required to conduct a walkthrough before and after each shiftNotification required.
Safety Plans:
	All Safety Plans are and will be adjusted throughout the stay of each client until discharged (d/c) from the facility, which include doctor's orders and changes that range as followed: q5, q15, and 1:1 supervision.
Orders that indicate 1:1 during wake hours, the sleep hours consist of staff positioned at the doorway of clients assigned sleeping area, ensuring that safety and supervision is carried outThis method can be advised by the LCCA, or and the AOC (Administrator On Call).
Method of Communication:
	The notification and communication methods of these changes are provided to the staff employed at Fort Behavioral Health include both via Teams and Shift Reports, as well as a DIRECT ORDER (documented) from Administration, ensuring that the proper rounds are being conducted for the safety of the client.

In closing, Fort Behavioral Health will continue to conduct the required trainings to all staff working with clients that are in care / treatment until discharged, ensuring that safety and supervision is provided under the rules of Minimum Standards. In addition, staff will continue to conduct rounds that are set forth or / and recommend within the Safety Plan, catering to needs of each client and made aware of any / all changes.
All staff will continue to be briefed on the history and made aware of all precautionary measures recommended upon intake, as well as a review / refresher on trauma and triggers during shift reports.
Fort Behavioral Health with continue to supervise, monitor, review, and train each staff placed on a Performance Improvement Plan (PIP), ensuring that the conditions are met under the rules and guidelines for Minimum Standards.
Fort Behavioral Health will continue to improve with great efforts with a Continuous Plan of Care for each client, adhering to Policy changes under the rules and guidelines for Minimum Standards.


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

raw_content: Children in care were allowed to remain in the same proximity when child restraints were performed.

Correction Narrative: Follow-up inspection occurred where case files of all staff members involved in an inappropriate restraint were reviewed. Staff members directly involved in the restraint are no longer present at the operation. Other staff members present during the inappropriate restraint received EBI training. Training certificates dated for 2/3/2023 were received to verify the training was completed.


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

raw_content: Child in care was restrained after staff demonstrated behavior that escalated the child.  Staff did not engage in appropriate de-escalation techniques.


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

raw_content: Staff conducted a restraint of a child where the child was lifted off their feet and taken to the floor.  The child sustained an injury to the hand.


summary: 748.685(c)(2) - Caregiver responsibility - provide a safe environment

raw_content: A child in care was under the influence of a substance, was behaving abnormally, and was not separated from the group during therapy.

Correction Narrative: On 03/22/23 an email was received stating that Staff have been trained in how to appropriately search for contraband in patient's belongings as well how to conduct room searches when warranted. An inspection on 04/03/2023 was conducted to confirmed that information provided was valid.


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

raw_content: A restraint was implemented on 02/07/2023. The documentation of the restraint is incongruent with what was observed on the video.

Correction Narrative: An email was received on 03/22/23 that informed Staff have completed a training regarding Serious Incident Reports and documentation. An EBI Committee has also been constructed in order to review footage of incidents, provide feedback to staff involved, and review documentation. On 04/03/2023 an inspection was conducted to the operation to ensure documentation submitted was valid.


summary: 748.2453 - Emergency Behavior Intervention-Only a qualified caregiver may administer emergency behavior intervention, except short personal restraint

raw_content: A caregiver implemented a personal restraint, prior to being trained in EBI.

Correction Narrative: participate in the inappropriate restraint were terminated. All person who observed the inappropriate restraint were retrained on appropriate EBI process and procedures.


summary: 748.2605(b)(2) - Personal Restraints Prohibited-Prone and supine restraints except as a last resort when other less restrictive interventions have proven ineffective

raw_content: A child in care was placed in a supine restraint for several minutes. There was no indication that this position was the most effective technique.

Correction Narrative: It was verified by inspection that all person who participate in the inappropriate restraint were terminated. All person who observed the inappropriate restraint were retrained on appropriate EBI process and procedures.


raw_content: 1 of 1 medication log did not provide a reason medication was prescribed.

Standard Number / Description: 748.2151(c)(3) - Medication record - must include reason medication was prescribed, for prescription medication

Correction Narrative:
RCCR Inspector received a compliance plan from interim LCCA with the following information in regard to cited standard:
Director of Nursing has/will complete a training with all of the current nursing staff regarding adding the justification for the medication on the MAR. Justification will continue to be entered on the actual orders by the MD. Future nursing staff will participate in the same training. A template of the electronic process in which the necessary information will be added to the medication log was provided as well.


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

raw_content: An admissions assessment completed on 01/21/23 documents that a child was abused. The information was not reported as required.

Correction Narrative:
RCCR Inspector received a compliance plan from interim LCCA with the following information in regard to cited standard:

All current staff of intake have/will complete an external training regarding Reporting Child Abuse. Any future intake staff will complete a similar training at orientation. Training certificates will be made available at HHSC request at any time.
Intake assessments have also been updated with a prompt to staff that If a child reports abuse, staff must report to the abuse Hotline. Under the prompt, a question was added for the Who did you report to at Hotline' and Report Number'.