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

raw_content: 2 of the 3 active child's medication records reviewed did not include an accurate count.

Correction Narrative:
The agency provided a corrective action plan for their medications. The plan states, "
1.	The agency has moved to a new system of bubble packaging of medication.  The system will eliminate errors in medication counts.
2.	The Administrator or designee will conduct a minimum of two medication audits monthly to ensure accuracy of count for the next three months.  (Begin December 13-March 13, 2022)"


state: TX

facility_name: A.B.E Residential Services

summary: 748.3301(c) - Physical Site-Windows & doors must be in good repair & free of broken glass or hazards

raw_content: 1 closet door, located in the child's room located in the first door to the right of the hall, is completely of the hinge and sitting in the child's room.

Category: Physical Site

Standard Risk Level: Medium High

Corrected at Inspection: No

Correction Narrative: The operation sent an email stating, "The closet door has been repaired.  (See attached documentation)"


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

raw_content: 1 incident report reviewed  showed that a staff performed a restraint on a child in care and has not had any EBI training.

Category: Individual Standards Evaluated

Standard Risk Level: High

Correction Narrative: Th operation sent an email stating, "Crisis Prevention Intervention and SAMA are tentatively scheduled.  CPI is tentatively scheduled for Friday, December 10, 9am-5pm; SAMA is tentatively scheduled, .  Staff Tami Minton has been removed from the schedule until training is completed.  See the revised scheduled attached.


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

raw_content: The operation has been without an administrator since 8/20/2021.

Standard Risk Level: Medium

Correction Narrative: The operation has an administrator effective 12/1/2021


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

Deficiency Narrative: The operation has been without an administrator since 8/20/2021.


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

raw_content: 1 incident report reviewed is missing the date of admission for the child involved.

Corrected at Inspection: Yes


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

raw_content: 2 of the 3 child records reviewed did not have an initial service plan

Standard Risk Level: Medium Low

Correction Narrative: 2 Service plans have been requested by caseworkers and will be sent as soon as they are received.


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

raw_content: 3 of the 3 child records reviewed did not include known contraindications to the use of restraints.

Correction Narrative: The reason for a restraint has been filled in for all incident forms.


summary: 748.1221(c)(1) - Admission Assessment-Document why a particular piece of information is unavailable

raw_content: The admissions assessments reviewed did not document as to why information was not available or obtained.

Standard Risk Level: Low

Correction Narrative: The 72 hour plans have been updated and any section that had N/A in the box has been fill in and completed.


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

raw_content: All 3 admissison assessments reviewed were not complete. Each one either had blanks or unanswered questions.

Correction Narrative: The 72 hour plans have been updated and any section that had blanks and was not answered has been fill in and completed.


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

raw_content: 1 of the 3 staff files reviewed did not have a completed Notarized Licensing Affidavit. The one in his file was completely blank.

Category: Personnel

Correction Narrative: The Licensing Affidavit has been completed and notarized.


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

raw_content: Some of the medicatioln records reviewed were missing the dosage.

Category: Medication

Correction Narrative: The operation sent an email with an updated medication log including the missing information.


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

raw_content: 1 of the 3 staff files reviewed did not have documentation showing the staff completed orientaton.

Category: Training and Professional Development

Correction Narrative: Staff has completed orientation and has a certificate of completion in the file.


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

raw_content: All 3 child records reviewed were missing immunization records.

Category: Child Care

Correction Narrative: Immunization records are updated and placed in each child's file.


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

raw_content: 2  of the 3 staff files reviewed did not have the start date of employment for the staff.

Category: Reports and Record Keeping

Correction Narrative: Staff start dates have been documented in their files.


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

raw_content: All 3 staff files reviewed did not include a job description.

Correction Narrative: The operation sent an email with the job description attached.


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

raw_content: 1 child's PRN medication log did not include the reason for administering the medication.


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: 1  of the 3 staff files reviewed did not include signed documentation that he will report suspected abuse and neglect.

Correction Narrative: The document is now signed and placed in the staff folder.


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

raw_content: 1 of the 3 staff files reviewed did not have documentaton (high school or college diploma) showing how the staff meets minimum qualifications.

Correction Narrative: The operation provided an email with the staff's high school transcript attached.


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

raw_content: 1 of the 3 staff files reviewed did not have documentation of having a TB test.

Correction Narrative: The operation sent an email verification of the staff's TB screening.


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

raw_content: None of the 3 child records reviewed had documentation on the exterior indicating whether or not the child has any known allergies.

Correction Narrative: The children's allergies have been added to the front of each child's binder.


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

raw_content: Medication records reviewed did not include the reason the medication was prescribed. The staff's name and signature are also missing.


summary: 748.153(3)(C) - Notification - Remove controlling person

raw_content: The operation no longer has an administrator and did not inform Licensing of this change.

Correction Narrative: The operation has removed their administrator as a controlling person.


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

raw_content: The operation has been without an administrator since 8/20/2021.


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

raw_content: No abuse and neglect policy

Category: Organization and Administration

Deficiency Narrative: No abuse and neglect policy

Correction Narrative: The operation provided a copy of their abuse and neglect policy


summary: 748.4213(a) - Emergency Care Discharge Plan-if child in care for more than 15 days, must have a written discharge plan for child from person responsible for child

raw_content: No preliminary discharge plan document

Category: Emergency Care

Deficiency Narrative: No preliminary discharge plan document

Correction Narrative: The operation provided their emergency care discharge plan document.


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

raw_content: The mock file did not include a preliminary service plan.

Category: Admission, Service Planning, Discharge

Correction Narrative: The operation provided a preliminary service plan.


summary: 748.105(1) - Personnel Policies - Develop a written organizational chart showing administrative/professional/staffing structures and lines of authority

raw_content: The operation s personnel policies did not include an organizational chart

Correction Narrative: The operation sent me an email that included their organizational chart.


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

raw_content: Policy does not include procedures for an employee to be exempt from having a required vaccine, procedures exempt employees must follow, prohibit discrimination against exempt employees, does not contain an outline of how a written or electronic record will be maintained of each employee's compliance with or exemption, and does not state the disciplinary actions you may take against an employee who does not comply.

Correction Narrative: The operation provided a copy of their updated policy that includes their vaccine preventable policy.


summary: 748.109 - Admission policies must include description of each program you offer

raw_content: No description of each program offered, no program goals, no characteristics of the population the program serve

Correction Narrative: The operation provided an updated copy of their policy that includes an updated admissions policy that has the missing information.


summary: 748.4209(a) - Placement Extension-Child's service planning team must document the reason for the placement extension in the child's record

raw_content: No placement extension document.

Deficiency Narrative: No placement extension document.

Correction Narrative: The operation provided a copy of their placement extension document.


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

raw_content: The serious incident report did not include the operation s address or phone number, and additional information required by 748.313.

Correction Narrative: The operation provided the serious incident document that included the missing information.


summary: 748.4231(a) - Admission assessment for emergency and respite care services-must include an initial evaluation of appropriate placement of the child

raw_content: Admission Assessment for Emergency Care Services did not include the time of placement, referral source, child s condition at the time of placement, child s understanding of the reason for emergency care placement, child s feelings about the crisis situation.

Correction Narrative: The operation provided me with an updated copy of their admission assessment that has all the missing information included.


summary: 748.113 - EBI policy - develop EBI policies if my operation is permitted to use EBI

raw_content: The policy does not provide detail on the way a child can report an inappropriate EBI or prohibitions for retaliation.

Correction Narrative: The operation emailed a copy of their EBI policy.


summary: 748.127(b)(2) - Operation plans, policies, and procedures formalized when signed by each partner in a partnership

raw_content: The policy has not been signed by each partner

Correction Narrative: The operation provided a copy of their signed policy and procedures


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

raw_content: Staffing plan does not include a backup plan for emergencies.

Correction Narrative: The operation provided a copy of their EBI policy


summary: 748.105(9) - Personnel Policies - Drug testing policy meets or exceeds DFPS' model policy in 745.4151

raw_content: No drug testing policy

Deficiency Narrative: No drug testing policy

Correction Narrative: The operation sent me an email with an attachment of their drug testing policy.


summary: 748.3273(1) - First Aid Kits-Each one must contain a current guide to first aid and emergency care

raw_content: First aid kit was missing scissors and thermometer

Category: Safety and Emergency Practices


summary: 748.111 - Child-care policy required

raw_content: The child care policy doesn't explain how a child obtains clothing, When trips with caregivers away from the operation are allowed and what protocols will be used, and child grievance procedures

Standard Number / Description: 748.111 - Child-care policy required

Correction Narrative: The operation sent an email with their updated childcare policy of the missing information.


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

raw_content: Medication log was missing the reason medication was prescribed, strength of the medication and signature for the person administering the medication

Correction Narrative: The operation sent me an email with their updated medication log that includes the information that was previously missing.


facility_name: Redicare

summary: 748.63(1) - Types of services-Operation must only provide services listed on permit

raw_content: The operation is providing services out of the scope of its permit. Specifically, the operation is providing care to a child outside of the permitted age range and offering ASD related services to children with autism.

Correction Narrative: Email received from the operation: "We are and have been working diligently with the SSCC to place these 2 children and get them moved as quickly as possible. One child was discharged Monday, 3/9/2026. The second child is also set to leave. Moving forward we will not provide services outside the scope of our permit."


summary: 748.311(6) - Serious Incident Documentation-Includes nature of the incident

raw_content: During a review of the incident report, it was found that the documentation did not clearly describe  the circumstances surrounding the child's injury involving a razor. The report lacked sufficient detail regarding what occurred, staff awareness, and the actions taken to ensure the chid's safety following the incident.

Correction Narrative: Moving forward Redicare oversight; administrator, treatment director and office manager will review incident reports for appropriate details and accurate record keeping.


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

raw_content: A child's admission date was documented as 1/14/2026 in a preliminary service plan, while the admission assessment had no date of admission. In a review of the visitor log, the child was not placed until 1/15/2026.

Correction Narrative: Redicare administrator and intake personnel will ensure that the operation clearly documents date of acceptance and the date of admission/placement.


raw_content: Communication form was observed to have inaccurate information about a child being present during an unannounced visit completed by the Administrator.

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

Correction Narrative: Redicare administrator/management will ensure documentation is more clearly detailed for accuracy.


raw_content: An incident report outlined that a child was dispensed OTC on 11/12/2025 and no medication record was available at the time of the visit. The operation later provided a medication record detailing when the OTC was dispensed, and date documented on the incident report did not align with the medication record.


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: There was no discharge/transfer documentation that outlined what the child's reaction was to discharge or other information such as list of medications, physical condition, etc.

Correction Narrative: Redicare staff have been retrained on documentation, to help promote clear consistency and accuracy.


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

raw_content: 3 out of 4 employee files reviewed contained training certificates missing the training hours.

Correction Narrative: An email was received from the operation with training certificates including the training hours.


summary: 748.3319(a) - Required Postings-Residential Treatment Center's must have

raw_content: During the inspection, I observed the no trespassing sign posted by the entry way missing the required verbiage.

Correction Narrative: An email was received from the operation with a screenshot of the confirmation page of the state website for the order of the required trespassing sign.


summary: 748.941(b) - Training Criteria- Training on emergency behavior intervention and administering psychotropic medication must be instructor-led.

raw_content: 2 out of 4 employees did not have instructor led psychotropic training.

Correction Narrative: An email was received from the operation with training certificates for psychotropic medication.


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

raw_content: 748.505(5)-Four out of four employee files reviewed did not contain affidavit form 2912 in the file, 748.505(6) (a)-2 out of 4 employees did not have verification of previous employment and did not have references verified.


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

raw_content: During the walkthrough of the operation, there was an open purse viewied on the kitchen counter with a staff member's OTC medication.


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

Correction Narrative:
During a heightened visit, a child's medication log was reviewed and there was no documentation if the child's prescribed Fluticasone was administered on 6/17/25.

Medication was audited for a child in care. There were no concerns with the medication log.


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: it was observed during todays inspection at the facility that the health inspectiton expired on 5-10-25. The administrator confirmed it has expired and that they have scheduled for the inspection to be completed tomorrow 6-14-25.

Correction Narrative: The operation sent its written correction via email. In its correction, the operation stated that henceforth they will be requesting for the health inspection on time before it expires. The operation also provided me with copy of the newly completed Sanatory inspection completed at the operation on 6-14-25.


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

raw_content: Child CONCERTA Medication was discontinued by the doctor upon child discharge from the hospital on 5-12-25. However, the medication log for CONCERTA for 5-12 and 5-13 did not state the medication was discontinued by the doctor at the hospital.

Correction Narrative: The operation stated that moving forward the med log has been adjusted to notate written changes concerning medication changes or adjustments.


raw_content: The operation is providing services to 2 children with a diagnosis of ASD, a service not listed on their permit.

Standard Number / Description: 748.63(1) - Types of services-Operation must only provide services listed on permit

Correction Narrative: A discussion was had with the Administrator on the importance of only providing services listed on their permit. The two children have had discharge notices put in and are pending discharge.


raw_content: A service plan reviewed did not list the child's Autistic disorder diagnosis.


summary: 748.3301(c) - Physical Site-Windows & doors must be in good repair & free of broken glass or hazards

raw_content:
Several windows at the operation did not have screens.

Note: This was corrected at inspection due to window screens recently being installed on windows.


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

raw_content: The victim child was seen on 3/6/2025 and was prescribed Clonidine 0.1mg to take 2 tablets in the morning and 1 table in the evening. A psychiatric evaluation was completed at In Touch Psychiatry on 3/11/2025 and reports that Clonidine is to be taken twice daily, once in the morning and once in the evening. However, after the change the medication log shows that clonidine 0.1mg was still given twice in the morning and once in the evening.

Correction Narrative: The victim child was seen on 3/6/2025 and was prescribed Clonidine 0.1mg to take 2 tablets in the morning and 1 table in the evening. A psychiatric evaluation was completed at In Touch Psychiatry on 3/11/2025 and reports that Clonidine is to be taken twice daily, once in the morning and once in the evening. However, the medication log for 3/12/2025-4/10/2025 shows that clonidine 0.1mg was still given twice in the morning and once in the evening.


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

raw_content: The serious incident report provided did not include the required components.


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

raw_content: The admissions assessment for the child's file reviewed did not include a signature from the professional level service provider.


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

raw_content: The daily count on a child's medication log was observed to be inaccurate.


summary: 748.681(2) - Caregiver qualifications- HS diploma or GED from program recognized by TEA, TPSAC, other state or documentaion of equivalency from home schooling

raw_content: The employee file viewed for a direct care staff member did not have a copy of the staff's high school diploma or GED.

Correction Narrative: Email received from the operation with appropriate education documentation for the staff file. No concerns were found.


summary: 748.3303 - Physical Site-Living quarters, recreation & dining areas, bathrooms, bedrooms, & kitchens must be adequately ventilated

raw_content: A bedroom window where a child in care currently resides in has been boarded up (interior) for approximately three months. There is no mechanical ventilation system.


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

raw_content: A staff member at the facility has worked with the operation for about two months and never had a completed drug test.

Correction Narrative: Received a corrective action plan from the administrator stating that RediCare administrator and office manager will ensure that pre-hire applicants have cleared drug test results, as part of their pre-employment testing.


summary: HRC42.056(g) - BGC-persons cannot provide direct care/have direct access to children without all required background checks unless they meet certain criteria.

raw_content: An employee has worked with the facility since September and never received an eligible status stating that he was cleared to work at the facility.

Correction Narrative: Received a corrective action plan from administrator stating that :RediCare administrator and office manager will ensure that all persons are completely cleared from required background checks, before providing direct care or have direct access to children.


summary: 748.1101(b)(4)(A)(v) - Children's rights- To be free from being subjected to remarks that belittle or ridicule the child or the child's family

raw_content: A staff member told a child in care they would not make it in the military due to their sexuality.

Correction Narrative: Monthly schedule was reviewed and the staff is no longer present.


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

raw_content: Multiple children in care are not being allowed to use the phone to call caseworkers and attorneys. Multiple caseworkers are having issues getting ahold of the facility.

Correction Narrative: The facility now provides the children a community phone that each can take a turn to make calls on to their casemanagers or attorneys daily.


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

raw_content: Multiple children in care reported staff sleeping on air mattress.

Correction Narrative: Walk through was completed. A chair was observed where staff sit when children sleep.


raw_content: I was observing the child's safety plan and noticed another child's name documented in it.

Standard Number / Description: 748.393(b)(3) - Active child record - Ensure record is kept accurate and current

Correction Narrative: Redicare GRO will ensure all child records are accurate at all times. Redicare GRO has retrained all staff in the facility in following all child services plans accurately. All Redicare current resident's documentation has been corrected and updated. Lauren Y. is no longer with Redicare.


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

raw_content: The child's service plan is not being followed.


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

raw_content: During a review of one of the child's files, a child in care was missing her signature on her child's right form.

Category: Children's Rights

Correction Narrative: Received corrective action plan from administrator. The child has reviewed and signed the acknowledgement of their rights- Moving forward the child's signature of acknowledgement, is added to the intake checklist. And monitored by both RediCare office manager and administrator.


summary: 748.363(11) - Personnel records-Include proof of request for background checks.

raw_content: During a review of personnel records, four employees were missing proof of request for background checks.

Correction Narrative: The facilities office manager sent over corrections on 9/23 with proof of one of the staff's requests for background checks.


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: During a review of personnel files, four employees were missing documentation of reference checks.

Correction Narrative: The facilities administrator sent over corrections on 9/20 with proof of reference check for one of the staff.


summary: 748.3319(a) - Required Postings-Residential Treatment Center's must have

raw_content: The facility did not have a required no trespassing sign posted.

Correction Narrative: The facilities office manager sent over a photo of the facility now having a no trespassing sign posted on 9/20 .


summary: 748.531(a)(2) - Child-care administrator-Licensed according to HRC Chapter 43 and Subchapter N of Chapter 745

raw_content: The operation's administrator has had an expired LCCA license for almost 2 months.

Correction Narrative:
An email was received from the operation's administrator providing a copy of the payment receipt for the LCCA renewal. This is the last task needed to complete the administrator's renewal packet.
A CAP was received via email on May 7, 2024 indicating the operation is anticipating on hiring a second LCCA to assist with the duties of an LCCA for the operation.


summary: 748.881(2) - General pre-service training curriculum-Includes measures to prevent, identify, treat, report suspicion of child abuse, neglect, and exploitation

raw_content: One out of three employee files reviewed did not contain all required components for the pre-service training curriculum.

Correction Narrative: A CAP was received via email on May 7, 2024 indicating the operation has created a checklist for pre-service trainings to ensure they are all completed timely.


summary: 748.753(d)(1) - Pre-Employment-You must document in the employee record each references name, relation, date completed, info obtained and name of interviewer.

raw_content: Two out of three employee files reviewed did not contain documentation of the reference and employment checks being completed.

Correction Narrative: A CAP was received via email on May 7, 2024 indicating the operation has included a reference form to the application packet for all new applicants.


summary: 748.1205(a)(7) - Admission Documentation-Includes child's immunization record

raw_content: Two out of three child files reviewed did not contain a copy of the child's immunization record or any documentation indicating attempts to obtain it.

Correction Narrative: A CAP was received via email on May 7, 2024 indicating the operation will begin sending emails to request missing documents to show tangible verification of the requests.


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

raw_content: One out of three employee files reviewed did not contain a copy of TB test results or a signed & notarized affidavit for employment.

Correction Narrative:
An email was received from the operation which included a copy of the missing TB test from the employee's file.
A CAP was received via email on May 7, 2024 indicating the operation will maintain a checklist for employee files to ensure all required documents are completed and placed in the file timely.


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

raw_content: One out of three child files reviewed contained conflicting names with signatures on a medical consenter form. The same child file also did not include the child's signature on the service plan. A few files reviewed contained other documents in them pertaining to other individuals.

Correction Narrative: A CAP was received via email on May 7, 2024 indicating the operation completed an audit on all child files and moving forward the administrator and office staff will conduct an audit of the files on a monthly basis.


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

raw_content: One out of three employee files reviewed did not contain the required 50 hours for annual training.

Correction Narrative: A CAP was received via email on May 7, 2024 indicating all employees missing training hours have scheduled their trainings to get caught up.


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

raw_content: The fire extinguishers upstairs and downstairs were both last inspected about 14 months ago evidenced by their tags which is over the required inspection timeframe.

Correction Narrative: Corrected.


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

raw_content: The operation has not entered EBI data in their provider portal for Quarter 4 of 2023.

Correction Narrative: The EBI report was generated in CLASS in which it displayed the missing quarter's information.


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

raw_content: One out of four youth files reviewed referenced another youth throughout their service plan and contained wrong admission dates on different documents in the file.

Correction Narrative: An email was received from the operation's administrator which included a corrective action plan indicating the document has been corrected and the error was addressed. It also indicated a review of files will be completed for accuracy. A copy of the updated service plan was also provided.


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

raw_content: Three out of four youth in care files reviewed did not contain an admission assessment that included the majority of the required information.


summary: 748.561(3) - Responsibilities of Professional level service provider-Completing a discharge or transfer summary for a child

raw_content: One out of four youth files reviewed did not contain a discharge summary.


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

raw_content: One medication record reviewed did not include the daily count.


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.


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

raw_content: Documentation was not completed for a medication count error.


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

raw_content: A caregiver didn't demonstrate prudent judgement when leaving medications unattended which resulted in a youth in care ingesting unprescribed medications.


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

raw_content: Three out of three employee files reviewed did not contain verification of suicide training being completed.

Correction Narrative: An email was received from the operation's administrator that included a corrective action plan indicating all staff were trained at once on suicide prevention. The email also included a training log dated December 1, 2023 that included the signatures of all the employees present.


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

raw_content: One out of four youth files reviewed did not contain documentation to show that the youth had a TB skin test.

Correction Narrative: An email was received from the operation that included a copy of the TB skin tests that were originally missing.


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

raw_content: During the inspection, there was observed a youth's nasal spray in an unlocked drawer in the kitchen.


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

raw_content: One out of four youth files reviewed contained a preliminary service plan that was not signed by a treatment director or a PLSP.

Correction Narrative: An email was received from the operation that included a copy of the signature page for the service plan showing the correct signatures on it.


Deficiency Narrative: One out of four youth files reviewed referenced another youth throughout their service plan and contained wrong admission dates on different documents in the file.


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

raw_content: Three out of three employee files reviewed did not contain documentation of the results of the reference and employment history checks.

Correction Narrative: An email was received from the operation's administrator that included the newly created form for pre-employment screenings to be utilized by the operation. The email also included a corrective action plan indicating the new form will be in every employee's file moving forward.


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

raw_content: Two out of four youth files reviewed contained a preliminary service plan that was completed more than the required 72 hours after their admission date.

Correction Narrative: An email was received from the operation's administrator that included a corrective action plan indicating the office supervisor will be responsible for ensuring service plans are completed timely moving forward.


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

Deficiency Narrative: Three out of four youth in care files reviewed did not contain an admission assessment that included the majority of the required information.


Standard Number / Description: 748.561(3) - Responsibilities of Professional level service provider-Completing a discharge or transfer summary for a child

Deficiency Narrative: One out of four youth files reviewed did not contain a discharge summary.


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

raw_content: Three out of three youth medication files reviewed contained count errors versus the actual remaining count of medications administered. One out of the three files reviewed had a medication dosage documented incorrectly.

Correction Narrative: An email was received from the operation's administrator that included a CAP indicating all staff are scheduled for a retraining of medication administration. After inquiring about the scheduled date, it was stated the training is scheduled for December 28, 2023.


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: Two out of four youth files reviewed did not contain a suicide screening from admission.

Correction Narrative: An email was received from the operation that included a copy of the missing suicide screenings.


raw_content: It was determined that a signature on the medical consent form was not signed by person listed.

Correction Narrative: An email was received from the operation's administrator, Tamra Oliver, that included a corrective action plan indicating a conference was held on October 24, 2023 with employees to ensure they don't sign documents for other people.


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

raw_content: The medication logs reviewed are prefilled for 7am and 7pm, which is not the time that multiple residence are receiving medication. The date that a resident was given medication at 2pm is still listed as being given at 7pm.

Correction Narrative: Corrected by in service training being completed.


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: Staff admitted to intentionally giving a child in care medication earlier than the child was supposed to receive the medication.


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

raw_content: Two fire extinguishers were observed to have an outdated annual inspection.

Correction Narrative: The operation has called and scheduled for the fire extinguishers in the home to be inspected. They have a date set for Friday, January 6, 2023.


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

raw_content: Refrigerated medication was observed to be kept unlocked in the refrigerator.


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

raw_content: During inspection, 3 of 4 records reviewed showed personnel with less than 50 hours of annual training.

Correction Narrative: The operation has taken additional trainings collectively which now equals to the required 50 hours for the staff who have been employed longer than one year.


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

raw_content: During inspection, it was verified that the treatment directdor doesn't work 32 hours per week. The treatment doctor works an average of 20 hours a week.

Correction Narrative: The operation stated they are in the process of hiring another Treatment Director and have submitted the individual's background check already.


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

raw_content: During review of records, it was found that 3 out of 4 records reviewed lacked documentation showing the amount of time caregivers attended transportation training.

Correction Narrative: An email was received from the operation's administrator, Tamra Oliver, which included the trainings logs for all caregivers at the operation. The training log indicated each training the caregivers completed to include the number of hours per each training.


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

Deficiency Narrative: During inspection, 3 of 4 records reviewed showed personnel with less than 50 hours of annual training.


summary: 748.3239(a) - Evacuation-Must practice unannounced fire drill at least once every 6 months from date of last fire drill

raw_content: There was only one fire drill documented as completed in an annual timeframe. There was no severe weather drill documented as completed. The fire drill was indicated to be completed over the required three minutes.

Correction Narrative: Most recent fire drill was done 12/6/22.  Calendar created to remind staff to complete fire drill. Staff have planned to complete fire drill monthly to get children in care used to the activity.


summary: 748.1703(c) - Menus-must date menus and keep copies for 90 days

raw_content: During the inspection, it was observed that the date on the menu showed 6/06/2021  6/12/2021.

Correction Narrative: During inspection, menu was updated to show current week. Staff have created future menus and will post them at the beginning of each week.


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: During inspection, it was noticed that 1 of 4 personnel records has only 8 hrs of EBI training completed within a month of hire but lacks the other 8 hrs of EBI training within 90 days.

Correction Narrative: Required 16 hrs of annual training completed by all employees. Documents verifying EBI training sent to operation representative.


summary: 748.4111(a) - Transportation records-Must maintain on file at the operation the name of each driver and a copy of that person's valid driver's license

raw_content: During the inspection, it was discovered a staff who transports children doesn't have a valid driver's license on file.

Category: Transportation


Standard Number / Description: 748.949(b)(5) - Annual Training Documentation-Includes the length of the training in hours

Deficiency Narrative: During review of records, it was found that 3 out of 4 records reviewed lacked documentation showing the amount of time caregivers attended transportation training.


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

raw_content: During inspection, 1 of 4 records indicated personnel's last EBI training had been completed over 6 mths ago.

Correction Narrative: EBI training was held for staff, including the staff member that was missing the 4 hrs of pre-service EBI training. An EBI training sign-in sheet was sent to inspector for verification.


summary: 748.3111(a) - Smoke Detector-Administrator or designee must test battery-operated smoke detectors monthly; date tested & name of employee that did test documented

raw_content: There was no documentation of the smoke detectors being tested monthly.

Correction Narrative: Monthly calendar created to remind staff to test smoke detectors. Section created on calendar for date, time, and staff signature.


raw_content: The treatment director was said to only work about 20 hours per week instead of full-time hours.

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


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

raw_content: It was discovered in this investigation caregivers forgot a youth alone at an event for about an hour before discovering the youth was missing.

Correction Narrative:
Interviews were conducted on January 30, 2023 with some of the youth in care at the operation to follow up on current supervision methods of the operation. Interviews have been entered in Chronology.

On 01/31/2023 administration provided a compliance plan. A meeting on Professionalism in The Workplace was held for all Redicare staff. Several items were covered in the meeting, including, employee general responsibilities and the Redicare Event Form. This form was created to help prevent this deficiency in the future.


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

raw_content: It was discovered during the investigation caregivers were not aware what the service plan stated for the supervision needs of the children.

Correction Narrative: Administration provided their compliance plan. A meeting on Professionalism in The Workplace was held for all Redicare staff. Several items were covered in the meeting, including, service plan review. Staff were informed that they must comply with notification, participation, implementation, and documentation requirements for an initial service plan. They were also informed where this information is located.


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

raw_content: Two staff members used inappropriate language while performing their assigned tasks.

Correction Narrative: On 12/5/22, an email was received from the operation's administrator, Tamra Oliver, requesting an extension to submit the correction. An extension will be granted until December 9, 2022. On December 9, 2022, the operation's administrator sent an email including a CAP along with a training sign in sheet dated 12-1-22 which indicated all staff were retrained on workplace professionalism.


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 child/caregiver ratio is currently 1:6 for children receiving treatment services.

Correction Narrative: The operation has discharged a youth and admitted one youth. A second youth is currently in the behavioral hospital and has a 24 hour discharge scheduled. The operation's current ratio is 1:5 as required per Minimum Standards.


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

raw_content: The operation failed to inactivate several employees no longer associated with the operation in the portal within the required timeframe.

Correction Narrative: An email was received from the operation's administrator that included a corrective action plan indicating the correction has been made and a notice has been posted to remind admin staff to do this in a timely manner.


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

raw_content: The operation's current employee list in the portal has not been validated in over three months.

Correction Narrative: An email was received from the operation that included a corrective action plan that indicated the correction had been made and a calendar reminder was set to ensure this task is done in a timely manner moving forward.


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: One out of three employee records reviewed did not include a TB skin test, a signed affidavit for employment, nor a signed acknowledgment for operational policies as well as reporting abuse/neglect.

Correction Narrative: An email was received from the operation's administrator that included a corrective action plan indicating the employee's file was audited and updated with the missing documents. A copy of the missing documents were also provided in the email.


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

raw_content: The operation has not reported any data regarding EBI's to Licensing.

Category: Emergency Behavior Intervention

Correction Narrative: An email was received from the operation that included a corrective action plan that indicated the correction had been made and a calendar reminder was set to ensure this task is done in a timely manner moving forward. The data was reviewed in an EBI report generated by the CLASS system.


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

raw_content: Three out of three employee records reviewed did not indicate a date of employment.

Correction Narrative: An email was received from the operation's administrator that included a corrective action plan indicating the employee's list was updated to include date of hire for each employee. A copy of the updated list was also provided in the email.


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

raw_content: A youth in care was on an unauthorized absence from the operation for more than 6 hours, and it had failed to be reported to Licensing.

Correction Narrative: An email was received from the operation's administrator, Tamra Oliver, including a corrective action plan that indicated staff were made aware of the timeframes to make reports to Licensing. The plan also indicated a poster has been posted at the operation to remind staff as well. A copy of this poster was also included in the email.


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

Deficiency Narrative: A youth in care was on an unauthorized absence from the operation for more than 6 hours, and it had failed to be reported to Licensing.


raw_content: The child/caregiver ratio was 1:7 for children receiving treatment services which resulted in runaways from the operation.

Standard Number / Description: 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


summary: 748.3421(2) - Poisons-The operation must ensure that poisonous or flammable materials are kept separate from medication, food, food prep and dining surfaces

raw_content: The pantry which has  food for the residence, also has cleaning supply, which should be kept seperate from food.


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

raw_content: Medication counts were off on two different prescribed medications.


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

raw_content: Staff file reviewed is missing the majority of the required trainings certificates or a collective sheet to indicate which trainings were taken.

Correction Narrative: An email was received from the operation's administrator that included a corrective action plan and copies of training certificates for the employee for verification.


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 youth in care did not receive a prescribed medication for three months.


Standard Number / Description: 748.363(11) - Personnel records-Include record of training and training hours

Deficiency Narrative: Staff file reviewed is missing the majority of the required trainings certificates or a collective sheet to indicate which trainings were taken.


summary: 748.363(4) - Personnel records-Include evidence of valid professional licensures, certifications, or registrations required for the position

raw_content: Staff file reviewed is missing education required documentation .


raw_content: Daily medication log was not documented to include the remaining count.

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

Correction Narrative: An email was received from the operation's administrator including a corrective action plan that indicated the medication logs have been updated to include the daily count. It also indicated lead staff will review the med logs daily as well. A copy of the new medication logs was attached to the email.


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

raw_content: Child records did not provide easy access to known allergies and chronic health conditions.

Correction Narrative: An email was received from the operation's administrator that included a corrective action plan indicating a face sheet was created that includes a space for known allergies or chronic conditions. A copy of the face sheet showing this information was also received in the email.


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

raw_content: Child's file did not contain indication that an orientation was provided as no signed documentation was located in the file verifying this.

Correction Narrative: An email was received from the operation's administrator that included a corrective action plan indicating the child has signed the child orientation document as verification. A copy of the document was also provided.


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

raw_content: Child's file was missing immunizations records.


Standard Number / Description: 748.363(4) - Personnel records-Include evidence of valid professional licensures, certifications, or registrations required for the position

Deficiency Narrative: Staff file reviewed is missing education required documentation .


raw_content: Child's file did not have signed orientation.

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


summary: 748.393(b)(2) - Active child record-Includes known allergies and chronic conditions or

Deficiency Narrative: Child records did not provide easy access to known allergies and chronic health conditions.


raw_content: Medication log daily log was not documented.


raw_content: Staff file reviewed is missing the required trainings.


summary: 748.1101(b)(4)(A)(ii) - Children's rights-The right to be free from being subjected to or threatened with corporal punishment, including spanking or hitting

raw_content: Staff threaten to use corporal punishment to child in care.


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

raw_content: Staff member used profane language to a child in care.


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

raw_content: One out of two child files reviewed had an acknowledgement of the child's rights signed by operational staff but not the child.

Correction Narrative: An email was received from the operation's administrator including a corrective action plan along with a copy of verification that indicated the youth signed the child's rights acknowledgement. The corrective action plan also indicated a youth checklist will be implemented to ensure this action is done at admission.


summary: 748.3273(4) - First Aid Kits-Each one must contain cotton balls

raw_content: Three out of five first aid kits did not contain cotton balls.


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

raw_content: One out of three employee records reviewed did not contain verification that a drug test was completed.

Correction Narrative: An email was received from the operation's administrator with a corrective action plan indicating the document was obtained and placed in the file along with a copy of the missing document for verification.


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

raw_content: One out of three employee records reviewed did not contain a signed Affidavit for Employment.


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

raw_content: Four out of five first aid kits did not contain a thermometer.


summary: 748.3273(6) - First Aid Kits-Each one must contain scissors

raw_content: Three out of five first aid kits did not contain scissors.


summary: 748.505(b)(2) - Minimum qualifications for employees-Record of a TB screening showing the employee is free of contagious TB as provided in 749.1583

raw_content: One out of three employee records reviewed did not contain verification of a TB skin test completed.


summary: 748.1205(a)(7) - Admission Documentation-Includes child's immunization record

raw_content: One out of two child files reviewed did not contain an immunization record or documented attempts to obtain.


raw_content: Two of the staff files reviewed did not contain information to verify educational requirements for the job positions.

Correction Narrative: An email was received that included the corrective action for this deficiency. A copy of verification of educational qualification was also included in the email for both staff.


summary: 748.1205(a)(6) - Admission Documentation-Includes medication the child is taking

raw_content: The operational Admissions Assessment document  does not state if the child is on medication and what medication the child is taking, if any.

Correction Narrative: An email was received that included the corrective action for this deficiency. The admission assessment was updated to include a section for medications the youth may be taking. A copy of the corrected document was provided as well.


summary: 748.115(5) - Discipline policy - Include a statement that discipline of any type is not allowable for infants

raw_content: No statement indicating discipline of infants in the discipline policy.

Correction Narrative: An email was received that included a corrective action plan to provide the statement added to the discipline policy regarding infants.


summary: 748.123(4) - Vaccine preventable policy - include employee procedures for exemption based on medical conditions or CDC precautions

raw_content: No policy on exempt employees for vaccine preventable diseases.

Correction Narrative: An email was received that included a corrective action plan to detail the revision of the operation's policy to be in compliance.


summary: 748.1437(4) - Discharge/Transfer Documentation-Must include copies of child's service plans while in operation's care for the past 12 months

raw_content: Discharge form is missing a place to document that service plans were given.

Correction Narrative: An email was received that included a corrective action plan informing the operation's discharge form was amended to be in compliance. A copy of the amended form was included as well.


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

raw_content: In one record reviewed it was missing the proof of education.

Correction Narrative: An email was received that included the corrective action plan and copy of the employee's transcript.


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

raw_content: Discharge form is missing the date and time child was informed.


summary: 748.115 - Discipline policy - The discipline policies you develop for children in care must be consistent with Subchapter M of this chapter

raw_content: The current discipline policy includes EBI as a discipline measure which is prohibited discipline.

Correction Narrative: An email was received including a corrective action plan that detailed the amendment made to the discipline policy to remove EBI as on of the levels of discipline.


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 form is missing a place to document for an emergency discharge/transfer.


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

raw_content: Discharge form is missing a place to document the information of who the child is being discharged to.


summary: 748.1437(6) - Discharge/Transfer Documentation-Must include copy of any treatment for a physical condition that is in progress and requires follow-up

raw_content: Discharge form is missing a place to document any medical follow needed.


facility_name: Prime Residential Care

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

raw_content: A child in care was found to be in another child in care bedroom during the incident.

Correction Narrative:
1. all staff participated in Supervision training 2/20/2026. One on one special staff training will occur Thursday, March 10. One on one entails continuous monitoring and reporting every 30 mins of the child's actions with staff initials. This refers to eye sight, hearing range, and arms length. Each one on one resident's time of one on one coverage has been added to their one on one logs. Please see attached*
2. Walkie talkies are being purchased for staff to communicate he/she needs the restroom. The staff is then required to hand off to another staff until he/she returns. This will occur in the meeting scheduled for Tuesday, March 10
3. Supervision training will be conducted quarterly. Documentation available upon DFPS request
4. During staffing, it will be determined on the staffing log who is responsible for the one on one at bedtime transition. During this meeting, all are present to include LCCA and Tx Director when applicable.
Transition time and staff is being placed on each one-on-one log; available for review. See attached* LCCA will monitor weekly and review. Lead staff will be responsible for ensuring it is completed and documented daily.


summary: 748.4763(a)(1) - Initial Service Plan- Include the plans to obtain alcohol treatment, substance abuse treatment, or both, for children who require it

raw_content: The child's service plan did not discuss a plan for treatment of substance abuse.

Correction Narrative: An alcohol/drug intake screening will be utilized prior to admission of the child.


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

raw_content: One requested personnel file was reported to be located at the LCCA personal residence.

Correction Narrative:
The operation sent the following corrective action plan via email:

The HR Manager will be notified monthly of all active records and verify they are on site.


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

raw_content: The operation had holes in the wall which exposed wired, there was mold growing in the ceiling and the attic lock was broken leaving it accessible to children s area in the second floor.

Correction Narrative: A walk through of the facility was condcuted. Areas identified as needing repair or attention were observed. No holes in the wall  or mold was observed and attic now has a lock.


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

raw_content: While conducting a walkthrough of the operation, multiple doors that have chemicals stored in were unlocked.


summary: 748.2103(a) - Medication Storage & Destruction-Discontinued or expired meds & meds left at the operation must be inventoried & stored separately from current meds

raw_content: There were three expired medications stored with other medications currently being used.


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

raw_content: It was found in childs files reviewed that there was no documentation of an orientation occuring or reason for omission.

Correction Narrative: As a correction the operation updated the children's records with an Acknowledgement of Handbook and Orientation form that all children have to sign.


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 documented suicide attempt that occurred on 05/01/2025 at or around 10:48 p.m. was not reported to Licensing until 05/02/2025 6:09 p.m.

Correction Narrative: Received a corrective action plan from the Treatment Director stating the following: The facility will have a designated back-up person to report suicide attempts   if the person witnessing the incident is not available.


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

raw_content: A suicide screening was not administered at admission for a child who has a history of suicidal ideations.

Correction Narrative: Received a corrective action plan from the Treatment Director stating the following: All residents will be administered the self-harm/suicide questionnaire upon intake.  The questionnaire will be reviewed by the Tx Director to assess the level of acuity. (An attachment was provided)


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

raw_content: A child in care threatened to self-harm and was admitted into a behavioral hospital on 04/26/25. There were no screenings conducted by the operation upon his discharge from the hospital. The child subsequently attempted suicide on 05/01/25.

Correction Narrative: Received a corrective action plan from the Treatment Director stating the following: A qualified Human Services professional will conduct an assessment of the resident within 24-48 hrs of being discharged due to suicidal attempts.  The assessment will be placed in the child's record


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

raw_content: It was found during an inspection that walls were in malrepair ,needed paint,blinds were broken in the living room downstairs, and there was exposed wires from an smoke dectector in a childs bedroom.

Correction Narrative: The operation is come into compliance with this minimum standard.


raw_content: It was found during an inspection that the second story banister was unstable and spindles were missing.

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

Correction Narrative: The operation has come into compliance with this minimum standard.


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

raw_content: It was found during a walkthrough of the grounds of the operation several fence posts were missing or in malrepair  in the backyard.

Correction Narrative: The operation has come into compliane with minimum standards


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

raw_content: It was found at the inspection that a child did not have a fitted sheet on their bed.


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

Deficiency Narrative: It was found in childs files reviewed that there was no documentation of an orientation occuring or reason for omission.


summary: 748.685(d)(3) - Caregiver responsibility- Child participating in unsupervised activity - caregiver must provide/arrange/ confirm transportation to & from activity

raw_content: It is alleged that the caregiver did not arrange suitable transportation home from the workplace for a child in care.

Correction Narrative: An email from the operation's administrator stated that the operation has developed a transportation plan for the child to ensure coordination of transportation before work shifts and as schedule changes occur. The operation has also scheduled staff for additional transportation training to be completed by the end of April 30, 2025.


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: There is no indication that the child's rights were reviewed with the child and that they understood their rights as the form was not signed by the child and did not indicate a reason why it was not signed.

Correction Narrative: A file checklist was created to ensure that all children have reviewed and signed the child rights.


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

raw_content: A child's admission assessment was not in the child record as required.


raw_content: The operation had rubbing alcohol and a cleaning agent in the kitchen accessible to children.

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


raw_content: In the laundry area and hallway it was observed that the ceiling is bubbled up and has mold.

Correction Narrative: The ceiling was repaired and was in good repair with no mold.


summary: 748.1101(b)(4)(A)(v) - Children's rights- To be free from being subjected to remarks that belittle or ridicule the child or the child's family

raw_content: Based on information gathered, it was determined one staff member uses profanity towards the children in care.


summary: 748.2851(b)(1) - EBI Follow-Up-Caregiver involved in EBI must conduct post discussion with child to discuss child's behavior and circumstances that required EBI

raw_content: Based on the information gathered, it was determined that staff does not inform children in care why they are being restrained when a restraint occurs.


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

raw_content: Based on the information gathered, staff did not appropriately handle a situation regarding administration of medication leading to a restraint.


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

raw_content: Medication logs reviewed, indicated medication was not provided to child in care as prescribed. In addition, there was no medical log for child's inhaler.


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

raw_content: Based on the information reviewed, it was determined staff conducted a restraint that caused impairment in child's breathing.


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

raw_content: The log did not indicate the date of the unauthorized absence.

Correction Narrative: An email from operation administration staff stated that: A staffing will be held by 12/20/24 with the objective to train staff on entering information for unauthorized absence in the absence of administration team. Documentation of staffing will be sent to licensing rep for the operation.


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

raw_content: The operation was made aware of the need for medical attention to an injury to a child on 9/16/24. Medical care was not provided until 9/18/2024.

Correction Narrative: A follow up was completed via inspection ID: 4030830. A log was created and will be reviewed by the Administrator, Case Manager and all staff for illnesses and injuries. In addition, a resident's refusal for medical treatment will be signed and dated. The form and log were observed.


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 waited 3 days to report an injury before going to the doctor.

Correction Narrative: All staff were retrained on documenting and reporting serious incidents. A training log was observed as well as certificates.


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: While reviewing staff records it was noted that reference checks were missing from a staff record.

Correction Narrative: Reference checks are being conducted prior to any training for all new hires.


summary: 748.3351(5) - Interior Space-provide bedroom windows with curtains, blinds, shades, or other provisions for rest and privacy

raw_content: During the walkthrough of the inspection, blinds were missing from the window in the downstairs bedroom close to the kitchen.

Correction Narrative: During the inspection bedroom 1 was observed to have blinds on all of the windows.


summary: 748.363(13) - Personnel records-Include record of training and training hours.

raw_content: There were multiple staff files with no training record to reflect the required components.

Correction Narrative: A training log was created.


summary: 748.463(a) - Unauthorized Absence EvaluationMust conduct an eval every 6 mths for unauthorized absences that have occurred during that time period

raw_content: The unauthorized absence evaluation is nonexistent.

Correction Narrative: The unauthorized absence evaluation wil lbe completed every 6 months and the next one will occur in January per the operation's plan.


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

raw_content: Serious Incidents are missing physical address, telephone number of the operation, the age of the child,  and follow up information after the incident.


summary: 748.3301(c) - Physical Site-Windows & doors must be in good repair & free of broken glass or hazards

raw_content: During the walkthrough, we observed an upstairs window that lacked a screen.

Correction Narrative: On 8/19/24, the operation submitted a correction plan indicating the screens have been replaced in all the windows in the home.  Pictures were provided as well.  There was a delay in getting the screens in due to the recent storm causing limited availability of the screens and installation.


summary: 748.3233(b)(2) - Evacuation-Emergency evacuation & relocation diagram must include designated location outside operation where all caregivers & children meet

raw_content: During the walkthrough, we observed the emergency evacuation plan lacked a designated meeting spot outside in case of fire or inside for inclement weather.

Correction Narrative: On 8/19/24, the operation submitted a correction plan stating the evacuation plans have been updated and posted in the operation.  Pictures of the updated evacuation plans were submitted, depicting the designated meeting places inside and outside the building.


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

raw_content: Sinks in the bathrooms throughout the operation were observed without soap or anything for the children to dry their hands with.


summary: 748.3161(a) - Heating Devices-Gas appliances must be safe and in good repair

raw_content: The gas stove was malfunctioning in that it emmitted a clicking noise.


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

Correction Narrative:
The showers do not have hot water and only has cold running water.
Went to the operation and checked the water pressure in two bathrooms and the hot water and cold water was accurate for the needs of children.


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

Correction Narrative:
There were multiple holes in the wall observed in one of the bedrooms upstairs, in addition one of the bedroom upstairs was observed with a broken window with shattered glass.
*Windown was fixed and holes were filled.


summary: 748.3061(2) - Gas Inspection-Operation inspected at least once every 24 months from date of last inspection for gas leaks

raw_content: The operations last Gas Inspection was conducted on 04/03/2021.

Correction Narrative: The operation was able to come into compliance by having there gas inspection completed on 03/27/2024


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

raw_content: A bottle of Multi Purpose cleaner was found in an unlocked cabinet in the kitchen.


summary: 748.453(a)(3) - Unauthorized Absence  Annual summary log must include how long the child was gone or if the child did not return

raw_content: The Unauthorized Absence log does not mention how long the children were gone.

Correction Narrative: To correct the specifics of this standard, the facility administrator shall ensure that the unauthorized absence summary log is adjusted to include the length of time the resident was gone from the facility, if he returns and specifically the summary log will also state if the child does not return.


summary: 748.457(a) - Unauthorized AbsenceTriggered Review of childs unauth absences must occur ASAP, but no later than 30 days after third absence within 60-days

raw_content: There was not a trigger review conducted for a child that  had run away 3 times within a 60 day period.

Correction Narrative: To correct the specifics of this standard the administrator in collaboration with the treatment director and case manager will ensure that unauthorized absence triggered reviews of child's unauthorized absence is completed and documented no later than 30 days after third absence within 60 days.


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

raw_content: Caregivers failed to institute a safety plan for two residents who both had high risk behaviors for sexually acting out and sexual aggression despite noting the plan would be put in place in the children's service plans. The two children were also placed in bedrooms directly across from each other despite the operation's knowledge of their alleged previous sexual interactions at their shared previous placement.

Correction Narrative:
The operation emailed corrections advising that the staff one staff always sits between the bedroom in question and going forward prudent judgement shall be practices in bedroom allocation. One of the residence is not longer in the placement.

on 11/29/23, Children living at the operation have been interviewed and advised of no concerns with supervision.


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

raw_content: Video footage reviewed during inspection showed a staff member sitting down engaged on their phone while two children in care walked up to another child and assaulted him by slapping, shoving, and punching them.

Correction Narrative: The operation has come into compliance with this standards.


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

raw_content: Staff member was using profane language towards children in care.

Correction Narrative: The operation has come into compliance with this standard.


summary: 748.4703(b) - Child/caregiver ratio-Caregiver must remain awake during night-time sleeping hours

raw_content: Two staff members sleep during night shifts.

Correction Narrative:
To address the specifics of these standaed rules the sitting positions of overnight staff was changed. Monitoring cameras are checked more frequently by the facility administrator  to ensure overnight supervision compliance. All staff are now retrained monthly during our staff monthly meeting to remind them of expectations regarding appropriate supervision.

Interview with the children at the operation were conducted and the child report no resent concerns with supervision or staff sleeping at night.


summary: 748.4653(a)(2) - Pre-Service Training- All caregivers must receive 16 hours of EBI training, if operation prohibits EBI then 8 hours only.

raw_content: There is no documentation to show that a staff member has completed pre-service EBI training.

Correction Narrative: The operation emailed the updated training certificates for EBI.


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

raw_content: Staff has not completed 4 hours of EBI ever 6 months.


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 took automobile keys from an unlocked drawer and drove off with another resident. The automobile belonged to the operation.

Correction Narrative: An email with attachment was received from the primary inspector for the operation. The van keys are no locked int he chemical closet with access to staff only. The garage door is now disabled. The treatment director has retrained staff have on appropriate supervision, understanding resident history, and supervision regarding behaviors.


raw_content: During the inspection, multiple were observed in the walls of the operation in various places. At least three holes bigger than the size of large fists were observed in the walls of more than one bedroom upstairs and behind the doors of at least one bathroom. There was one exceptionally large hole in onoe bedroom where planks of wood were exposed through the hole on the other side of the wall. Pieces of the wall were observed on the floor of the bedroom. Missing rail posts on the stairway were also observed in two different places. Lighter fluid was observed outside of the residence in the backyard near the trash.

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

Correction Narrative: This standards was found to be compliant.


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

raw_content: During the inspection, it was observed that multiple items in the freezer and the pantry were not properly stored. Expired items were also observed in the freezer and pantry as well.


summary: 748.3301(g) - Physical Site-The grounds must be free of garbage & debris & maintained in a sanitary manner

raw_content: During the inspection, a pile of trash bags were observed outside of the home in the backyard. The trash was not in a trash can.  The trash had a distinct smell and flies were surrounding the garbage.


raw_content: A child on 1:1 supervision was not being adequately supervised. A child in care on 1:1 supervision stated he is not always supervised 1:1.

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


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

raw_content: Child in cares service plan stated the wrong name in several sections.

Correction Narrative: The operation Administrator emailed over a corrective action plan for the deficiency stating that the child's service plan has been corrected and the Administrator and Case manager will continue to verify to ensure service plans are correctly tailored with the right child's name.


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

raw_content: In review of multiple medication records, it has been found that multiple med logs do not match the count of the pills in the pill packs and bottles.

Correction Narrative: An inspection was conducted, and the operation has come into compliance for this standard.


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

raw_content: Both fire extinguishers in the kitchen area are out of compliance, as the last fire inspection for extinguisher was conducted in February 2022


raw_content: a staff member made the choice to have a child in care get out of the car to follow another child in care to convince him to get in the car instead of contacting the operation/ law enforcement that she knew where the child in care was.

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

Correction Narrative:
Prime Residential RTC will continue to be trained and re-trained to exercise prudent judgement and always follow facility policy and procedures. This will be enforced by the administrator.
On 01/05/23 interviews were done with current residence of the operation. They were each spoken to about supervision, basic needs, discipline and restraints. No new concerns. -Ashley Russell


summary: 748.125(b) - All employees and caregivers must be aware of and follow your operation's policies and procedures

raw_content: Staff did not follow the operations policy in regard to cellphone use.

Correction Narrative: Aderemi Oso, Facility Administrator provided the inspector with an updated copy of policy regarding cell phone usage. Staff was provided a copy of the new policy and procedure.


raw_content: Staff provided resident with a cellphone.

Correction Narrative: Aderemi Oso, Facility Administrator provided the inspector with an updated copy of policy regarding cell phone usage. Staff was provided a copy of the new policy and procedure. Staff that provided resident with cell phone was terminated.


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

raw_content: Each medication log is missing the reason the residence are receiving the medications.

Correction Narrative: All medication logs have been updates to list the reason the medication is being given.


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

raw_content: While counting medications, it was found for multiple medications, there was more medication is missing from the pill packs, than recording as administered on the medication logs.

Correction Narrative: All medication has been reviewed counted and meets compliance.


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 directions advise that medication is to be taken every 3 hours but medication has been administered once daily.

Correction Narrative:
on 8/11/22 the operation submitted correction and advised that the operations admin' will be conducting weekly reviews of logs and has update information on the medication forms to assist staff with better documentation pratices.

on 8/23/22 All med logs have been observed to be updated to assure medication will be given as prescribed. Medication logs have been reviewed and medication counted has been conducted.


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

raw_content:
Light fixtures has wires expose and it hanging from
the ceiling.

Correction Narrative: Photo in share point


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

raw_content: There are two residence under the age on 10 and under the height of 4'9 that require booster seats when being transported, the operation, does not have booster seats for either child.

Correction Narrative: Pictures were received on the boosters seats and are in compliance.


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

raw_content: A child in care was inappropriately restrained leading to injuries.

Correction Narrative:
On 01/05/23 interviews were done with current residence of the operation. They were each spoken to about supervision, basic needs, discipline and restraints. No new concerns.
email on 12/21/22: The Staff directly involved in this incident is no longer a staff member of Prime Residential Care. To address the specifics off this standard rules, all staff members of the operation will continue to train and re-train all staff regarding appropriate was to avoid restraints and right position during restraints. This will be coordinated and enforced by the administrator.


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

raw_content: A child in care was restrained by a staff in a prone position.


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

raw_content: A child in care was restrained in a manner that obstructed the child's breathing.


raw_content: Three of 4 children had knowledge that the incident took and the children were left unsupervised.

Correction Narrative:
The staff member directly involved in the is negligence is no longer a staff member of Prime Residential Care. The address the specifics of theis standard rules, all staff members of Prime Residential Care will continue to be retrained on "Appropriate Supervision and Childcare Ratio" be the facilities Administrator to ensure minimum standard compliance.
Interviews with residence regarding supervision, can be found in chronology.


summary: 748.453(a)(3) - Unauthorized Absence  Annual summary log must include how long the child was gone or if the child did not return

raw_content: The operation has not developed an unauthorized absence log.

Correction Narrative:
to address the specifics of this standard rule, and to prevent future occurrences, the operation has developed Resident Absent witout leeave form that will be filed in a binder titled AWOL LoG.
The new for has been uploaded into sharepoint.


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: Resident does not have documentation for a TB exam.

Correction Narrative: Operation emailed over copies of TB test results for each resident.


raw_content: Medication log shows that a child's last AM pill was given on 4/4/22 with a remaining 6 pills. The medication pack shows 5 pills are remaining. Documentation does not show that the pill was given or refused.

Standard Number / Description: 748.2151(b)(1) - Medication record - update cumulative record within 2 hours of administering medication


raw_content: Medication log is missing the reason the medication is being taken on each of the medication logs.

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

Correction Narrative: diagnosis and reason for taking medication column was completed for all residents, the case manager under the direct supervision of the facility administrator will ensure this is always completed for all residents. attachment has been uploaded into sharepoint.


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: Fire extinguisher inspection expired Jan 2022

Correction Narrative: The operation has emailed over pictures and documentation for the fire extinguishers being inspected and have come into compliance. documents have been uploaded into SharePoint.


summary: 748.3239(d) - Evacuation-Must document fire and severe weather drills, including date, time, type of drill, and length of time for evacuation/relocation

raw_content: Operation needs evacuation drill forms.

Deficiency Narrative: Operation needs evacuation drill forms.

Correction Narrative: The operation emailed over a copy of the evacuation drill form which has been uploaded into SharePoint.


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

raw_content:
In review of the two staff files the items list below were missing:
A copy of the record of tuberculosis screening,
A statement signed and dated by the employee documenting that the employee has read a copy of the operational policies required
A statement signed and dated by the employee indicating the employee must immediately report any suspected incident of child abuse, neglect, or exploitation to the Texas Abuse and Neglect Hotline and to the operations administrator or administrators designee
A current job description
Documentation showing the date of employment

Correction Narrative: The operations administrator has emailed me a copy of all missing documentation which has been uploaded into SharePoint.


summary: 748.2101(3) - Medication Storage-Store medication covered by Schedule II of the Texas Controlled Substances Act under double lock in a separate container

raw_content: Schedule two medication need to be a a location where they can be double locked.

Correction Narrative: The facility sent me a photo that has been uploaded into sharepoint of the medication being moved to an area where it is able to be double locked.


summary: 748.3001(b) - Sanitation Inspection-Each inspection must meet regulations of the local health department ordinances

raw_content: The facility has not had a health inspection conducted.

Correction Narrative: Facility has had a environmental inspection completed. Documentations has been uploaded into sharepoint.


summary: 748.3301(c) - Physical Site-Windows & doors must be in good repair & free of broken glass or hazards

raw_content: In two bedrooms there were exposed screws found