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

raw_content: It was reported by the operation that a Suicide Screening was not completed related to the incident regarding this investigation. In addition, a Suicide Screening was also not conducted for a previous incident as reported by the operation.

Correction Narrative: As per the Administrator, a trigger has been added to Extend Reach, platform for documentation. In the event a child is admitted to the hospital, the trigger will trigger a suicide screening for 30 days after admission. A Suicide Screening Assessment that will be used by the operation was provided reflecting where the child's name and their pertinent information is to be documented.


state: TX

facility_name: St Peter - St Joseph Childrens Home Emergency Shelter

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

raw_content:
During a review conducted on [June 10, 2025], it was determined that:
(1)	your operations administrator failed to ensure compliance with the current HM Plan; and
(2)	12 months had elapsed since the effective date of the plan.
As you know, the heightened monitoring plan for your operation included a specific planned end date at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of post plan monitoring.  As a direct result of the administrators failure to ensure timely compliance with heightened monitoring plan, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operations planned end date must now be revised, and the period of heightened monitoring must be extended.
Further details of the administrators failure to ensure compliance include the following:
Your operation received a medium high weighted citation in a pattern/trend category on April 28, 2025.  Specifically, the operation was cited for 748.507(2): Employee general responsibilities-Staff failed to report concerns for physical abuse of a child in care by another staff. The operation met compliance on 05/06/2025.
Select those that apply, delete the other(s):
-	Operation failed to satisfy the conditions of the plan
-	Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and
-	Operation was unable to meet compliance with Medium-High or High weighted licensing citations.

Category: Individual Standards Evaluated

Standard Risk Level: Medium High

Corrected at Inspection: No

Correction Narrative: An HM extension was approved effective 6/9/2025.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your GRO in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 748.535(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is 12/10/2025.


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

raw_content: A caregivers intervention in a childs behavioral incident lacked competency and prudent judgement due to the caregivers aggressive approach that appeared to have further aggravated the childs behaviors.

Correction Narrative: Staff member confirmed a refresher training was completed.


summary: 748.507(2) - Employee general responsibilities-Report suspected abuse, neglect, and exploitation to Child Abuse Hotline and the designated employee/administrator

raw_content: Staff failed to report concerns for physical abuse of a child in care by another staff.

Correction Narrative: staff member interviewed stated that a reporting refresher was completed.


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

raw_content: A caregiver did not use the minimal amount of force when they utilized an inappropriate restraint technique, resulting in the child being thrown to the ground

Standard Risk Level: High

Correction Narrative: Staff member interviewed confirmed taking the EBI refresher course.


raw_content:
Dear Provider:
During a review conducted on December 9, 2024, it was determined that:
(1)	your operations administrator failed to ensure compliance with the current HM Plan; and
(2)	12 months had elapsed since the effective date of the plan.
As you know, the heightened monitoring plan for your operation included a specific planned end date at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of post plan monitoring.  As a direct result of the administrators failure to ensure timely compliance with heightened monitoring plan, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operations planned end date must now be revised, and the period of heightened monitoring must be extended.
Further details of the administrators failure to ensure compliance include the following:
Your operation received a medium high weighted citation in a pattern/trend category on August 28, 2024.  Specifically, the operation was cited for 748.2003(b)(3): AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders. The operation met compliance on 09/10/2024.
-	Operation failed to satisfy the conditions of the plan.
-	Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and
-	Operation was unable to meet compliance with Medium-High or High weighted licensing citations.
Finding: 748.535(2)  The licensed administrator must ensure the operation complies with current heightened monitoring plan.

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

Correction Narrative: An HM extension was approved effective 12/9/2024.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your GRO in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 748.535(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is 6/10/2025.


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: One child was administered a PM medication in the AM.

Correction Narrative:
8.28.24: according to the Program Director's email, the staff member involved in administering medication incorrectly was issued a corrective action and is taking preventing medication errors training.  An approved designee will also complete medication checks when the staff member is in charge of administering medication.
9.9.24: completed a site inspection.  reviewed 5 medication logs.  no concerns found.  Administrator stated that only the 3 supervisors are administrating medication now.


raw_content: One child in care was given a PM medication in the AM.

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

Correction Narrative:
6/3/24: according to the Administrator Email: the staff involved will be issued a corrective action and shift supervisors will be in charge of administering medication now and if they are off then one designated staff member will administer medication.
6/17/24: conducted an unannounced inspection.  reviewed 5 medication logs, no concerns were found.   Reviewed 2 staff medication training and they were update.  child in care whose log had the medication issue is no longer at the operation.


raw_content: According  to the medication log, a child in care did not receive the second dose of medication at noon as prescribed.

Correction Narrative:
4/22/24: According to the compliance response sent by the Administrator: Staff involved in the medication error will be receiving a corrective action.  Staff returns to shift tomorrow at which time LCCA will review medication administration policies.  Program Administrator has been reviewing medications on a daily basis to ensure administration of medications.  Supervisors in training will begin doing so on the weekend.  Additionally, LCCA set an alarm to remind staff to administer the noon medication on non-school days.
5.8.24: site inspection was completed.  The child in care's medication logs were reviewed.  Medication is being administered as prescribed.  3 additional medication logs were reviewed and compliant.


raw_content: 2 of the 5 children in care whose medication logs were reviewed were given medication twice in one day when the medication is prescribed for once a day.  1 of the 5 childrenin care whose medication logs were reviewed had a medication given 10 hours after the previous medication was administered when the medication should be given every 12 hours.

Correction Narrative: 3/26/2024: According to the compliance response emailed from Administrator: Program Director met individually with each staff administering medications to go over the 6 Rights of Medication Administration.  Staff involved in the medication errors received corrective action.  Supervisor/Staff in Charge is to be present during medication administration during the evening hours as this is typically when the errors have occurred to provide additional oversight.  Staff will also announce over the walkie talkie to request additional oversight when child is requesting medication outside of normal administration times.


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

raw_content: Video surveillance shows staff pushing a child.

Correction Narrative:
2/19/2024
according to email sent by Administrator: Staff was terminated as a result of the findings of this investigation.  Additionally, training has been developed to address behaviors staff are likely to encounter when working with children and how to appropriately address these behaviors.
2/29/2024
Rep completed a follow up to ensure trainings are being completed as well as interviewed staff on discipline.


summary: 748.1337(b)(1)(D)(vi) - Initial Service Plan-Include instructions to caregivers about behavior intervention techniques

raw_content: Behavioral intervention techniques, behaviors, and behavioral needs/goals are not present within a child's service plan.

Correction Narrative:
2/19/2024: Administrator stated that the following via email: information was shared with case managers to ensure all service plans include any behaviors and techniques to deescalate listed behaviors to better understand the child.  Weekly meeting will be held with PD, supervisors and case managers to discuss any behaviors concerns and de escalation techniques for each child in our care.  Additionally, all POSs were reviewed and corrected as part of the HM plan.

2/29/2024 An in-person inspection was completed.  verified missing information was in child in care's service plan.  EOS binders in each house includes the behavioral needs for each child in care and is signed by staff.


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

raw_content: It is corroborated that staff yelled at a child in care.

Correction Narrative:
2/19/2024
According to email from Administrator:  Staff was terminated as a result of the findings of this investigation.  Additionally, training has been developed to address behaviors staff are likely to encounter when working with children and how to appropriately address these behaviors.
2/29/2014
This training attendance sheet was evaluated to ensure training is being conducted.  Next training is on 3/8/24 for the rest of staff to complete that were not able to attend this training.   Staff interview was conducted as well to discuss discipline.


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:
A passenger van did not have a working seatbelt during transportation of children. The work ticket was not submitted in a timely manner where youth in care was not properly supervised by a caretaker as required.
Ticket 121 was presented on 7/13/23 to be fixed.

Correction Narrative: An inspection was conducted at the operation on 9-6-23. Video and still images were taken of the seat belt working effectively. The operation informs Van 1 is no longer in use for children in care since the seatbelt required fixing. Video and images uploaded into Class.


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

raw_content: Medication records were found to to be incomplete.  The medication record did not indicate the reason for the prescription.

Standard Risk Level: Medium

Corrected at Inspection: Yes


summary: 748.2551(a) - EBI Implementation-Must be an appropriate response to the behavior demonstrated, and de-escalation must have failed

raw_content: A caregiver implemented EBI when a child in care was in crisis and in response to the child being reluctant to walk down the hallway and into the living room area.

Correction Narrative: The agency informed via email and telephone call,  staff involved was terminated as a result of the findings of this investigation.


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

raw_content: A caregiver did not document EBI used for a child in care and did not do so within 24 hours.


raw_content: A suicide screening was not conducted after a child in care expressed suicidal ideations to a caregiver and made a suicidal gesture.

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

Correction Narrative: The agency informed via email and telephone call,  staff involved was terminated as a result of the findings of this investigation. Additionally, Supervisors and APD went over the agency policy regarding suicidal statements/gestures with all program staff.


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

raw_content: A caregiver's training certificate for suicide did not document the length of the training in hours.

Standard Risk Level: Medium Low

Correction Narrative: The agency shared the information with the Training Team to ensure all certificates include the length of training in hours.


summary: 748.685(c)(5) - Caregiver responsibility - ensure continuity of care by sharing information concerning each child with incoming caregivers

raw_content: A child in care expressed suicidal ideations and made a suicidal gesture, but the information was not passed on to incoming caregivers and/or documented and shared with the child's treatment team.  The fidget toy the child wrapped around his neck was taken away by the caregiver, but the child still had another fidget toy the same as the one used to wrap around his neck in his possession.  Therefore, incoming caregivers were not aware that the child was trying to use the toy to self-harm.

Correction Narrative: The agency informed via email and telephone call; staff involved was terminated as a result of the findings of this investigation. Additionally, APD and Supervisors reiterated the need for staff to communicate with the person coming in to relieve them from their shift. A communication notebook has been started in each house to ensure this occurring.


summary: 748.3563(d) - Protective Surfacing-Must ensure 9 inches of the loose-fill materials are maintained at all times

raw_content: There were areas at the playgrounds where loose-fill materials was not kept at a safe level where children in care may have a safety risk.


summary: 748.4657(1)(A) - Annual Training-Every 6 months a caregiver must complete at least 4 hours of training in EBI

raw_content: A staff member has not received her 6 month annual training for SAMA/ EBI. The staff chart also included a sticky note indicating the staff member was overdue.


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 EBI quarterly report was not submitted to Licensing, 15 days after the end of the 4th quarter. The quarterly report for the 1st quarter was not submitted to licensing.

Category: Emergency Behavior Intervention


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

raw_content: Evacuation Plans at exits in the kitchen area do not provide a designated area to meet outside the operation.


summary: 748.3443(a)(3) - Food Preparation-Food items must be protected from contamination

raw_content: The kitchen area had several food products  opened, not labled and expired in the refrigerator and /or freezer, food items were also observed on the floor.


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

raw_content: The sleeping quarters for both the girls and boys were unkept and the bathroom area had dirty towels on the floor. A shower head in the the girls dorm area was leaking water and staff stated it had been like that for several days.


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

raw_content: Sleeping quarters at the Intake building required for children to cross a hallway  and  living space area to have bathroom access.

Standard Risk Level: Low

Correction Narrative:
The following Corrective Action Plan was developed in response to the Unannounced Monitoring visit completed on January 23, 2023 at St. Peter-St. Joseph Children's Home Emergency Shelter, Operation # 817874.
Bedrooms will not be used for isolation rooms going forward and will return to previous purpose of infant/toddler rooms as evident by changing stations in the rooms.


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

raw_content: A child in care was left unsupervised in a bedroom and climbed onto a shelf of cubbies and fell and hit the back of the head on a metal bedframe on the way down. As a result, the child sustained a laceration.

Correction Narrative:
The operation emailed a Corrective Action Plan indicating the following to meet minimum standards:
Vice President of Programs and Licensed Child Care Administrator met with staff regarding supervision expectations; supervisors to conduct random in-person and video footage checks to monitor staff supervision.


summary: 748.4213(d) - Emergency Care Discharge Plan-the preliminary discharge plan and weekly reviews must be available for Licensing review

raw_content: There was no record of preliminary discharge plan being reviewed and updated at least weekly.

Correction Narrative:
The following Corrective Action Plan was developed in response to the Deficiency received during the Unannounced Investigation in October 2022 for St. Peter-St. Joseph Children's Home Emergency Shelter, Operation # 817874.

Vice President of Programs and LCCA met with the case managers to go over requirements for discharge planning and to discuss a plan to ensure this occurs going forward.


raw_content: There was no EBI documentation for a personal restraint.

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

Correction Narrative:
The following Corrective Action Plan was developed in response to the Deficiency Upheld in November 2022 for St. Peter-St. Joseph Children's Home Emergency Shelter, Operation # 817874.
Standard
748.2855 (a) EBI
EBI not documented	01/11/2023
Staff involved are no longer employed at St. PJ's.  Additional training was provided by VP of Programs and LCCA to staff as well as to Supervisors and Case Managers to ensure all documentation is complete by the end of the staff member's shift.


raw_content: Child was not displaying any behaviors that warranted any emergency behavior intervention.

Standard Number / Description: 748.2551(a) - EBI Implementation-Must be an appropriate response to the behavior demonstrated, and de-escalation must have failed

Correction Narrative:
The following Corrective Action Plan was developed in response to Investigation, #2936810, completed on October 28, 2022 at St. Peter-St. Joseph Children's Home Emergency Shelter, Operation # 817874.
Provided reminder to all employees on EBI policy and de-escalation policy and will be on-going.
Recommendation for termination submitted for employee involved in containment.
Will develop additional corrections based on information provided from de-briefing meeting.


summary: 748.2857(a) - No later than 72 hours after the initiation of the intervention, you must provide written notice to the parent.

raw_content: Parent, managing conservator, was not notified within the required timeframes of restraint.

Correction Narrative:
The following Corrective Action Plan was developed in response to Investigation, #2936810, completed on October 28, 2022 at St. Peter-St. Joseph Children's Home Emergency Shelter, Operation # 817874
Will develop plan based on additional information provided from de-briefing meeting.


summary: 748.1339(c) - Initial Service Plan-Child & parent must be invited to meeting to develop service plan & discuss participation in childhood activities

raw_content: Two Initial Service plans were reviewed. There is no indication that the children participated in the service plan meeting. The documents were missing signatures, where a child would sign.

Correction Narrative: On 11-22-22 the Administrator submitted a CAP in response to the citation. The Administrator met with the assigned Case Manager to ensure knowledge of standard and developed more detailed documentation training for new Case Managers


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

raw_content: Two Initial Service Plans were reviewed. The children's parents/legal guardians were not invited to participate in the children's service plan meeting.

Correction Narrative: On 11-22-22 the Administrator submitted a CAP in response to the citation. The Administrator met with the assigned Case Manager to ensure knowledge of standard and developed more detailed documentation training for new Case Managers. And updated timelines for sending letter to within first week of arrival if not given at admission.


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

raw_content: Staff should use attempt de-escalation techniques before attempting EBI. Staff needs to demonstrate knowledge of approved EBI techniques.

Correction Narrative: The shelter informs the staff member is no longer employed at the facility, and staff have undergone further EBI training on how to use de-escalation techniques to further avoid using any form of restraint.


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 inappropriately touched another child by grabbing them in the private area. The child's supervision level was line of sight and the staff member failed to provide adequate supervision to the child.

Correction Narrative:
On 07/22/22, email was received from operation with the following compliance plan.

Staff involved in this incident is currently on leave and will complete supervision training and sign supervision acknowledgement before returning back to work.

Scheduled training for all domestic staff for effective supervision on 07/22/22 and 7/28/22.

All staff will review and sign policy and procedure for appropriate supervision by 07/22/22.


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

raw_content: Kiddie Cottage one of the rooms missing a piece of siding and had protruding nail head. Outlet cover missing in the same room.

Correction Narrative:
February 22, 2022

Texas Department of Family and Protective Services
3635 S.E. Military Dr.
San Antonio, Texas 78233

Attention: Vanessa Reyes

The following Corrective Action Plan was developed in response to Investigation, #, completed on February 22, 2022 at St. Peter-St. Joseph Children's Home Emergency Shelter, Operation # 817874

Standard	Deficiency Specifics	Date of Correction	Correction Specifics
	During an unannounced licensing visit, 2 hazardous items in need of repair were found in the Kiddie Kottage dorm. 	2/22/22 and ongoing	Upon finding the items in need of maintenance, they were immediately corrected and before and after photos were submitted to licensing.

All staff were reminded to submit tickets to maintenance whenever a potential hazard is seen so that maintenance can repair it quickly.

If you have any questions or need additional information, please feel free to contact me.


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

raw_content: An active Employee who provided direct care to children had an inactive background check.

Correction Narrative:
The following Corrective Action Plan was developed in response to Investigation, #2818460, completed on July 20, 2021 at St. Peter-St. Joseph Children's Home Emergency Shelter, Operation # 817874

Standard	Deficiency Specifics	Date of Correction	Correction Specifics
745.641 AP Background check results-Must receive notification prior to allowing subject to be present at your operation 	An active employee who provided direct care to children had an inactive background check	1/14/22 and ongoing	Upon finding the error, HR was notified and immediate re-ran the inactivated background check.

HR was notified that we have 7 days to inactive a background check and that they should be completing quarterly audits to ensure that all backgrounds are properly marked active or inactive in the system.


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

Correction Narrative:
The following Corrective Action Plan was developed in response to Investigation, #2818460, completed on July 20, 2021 at St. Peter-St. Joseph Children's Home Emergency Shelter, Operation # 817874

Standard	Deficiency Specifics	Date of Correction	Correction Specifics
748.1331(a) Preliminary Service Plan-Complete plan that addresses child's immediate needs within 72 hours of admission	Child's Service Plan was not completed within 72 hours of admission and did not address supervision needs.	1/14/22 and ongoing	Lead Case Manager completed an audit for the prior quarter to ensure compliance.

 Staff maintain a caseload tracking sheet with due dates-lead case manager will check these weekly to ensure dates are met.

Case management department will complete a monthly file audit of all children's files to ensure compliance.

Lead case manager created a new intake checklist where all items are due within 48 hours by case managers. Lead case manager will ensure completion of these items through auditing.

Lead case manager completed training with case management department about including supervision needs on the preliminary service plan under additional needs.


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

raw_content: The freezer located in Flores Girl's dorm did not have a working thermometer. A replacement thermometer was replaced in the freezer during inspection.


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

raw_content: A staff member had inappropriate relationships with children in care.

Correction Narrative: Corrective action plan was developed in response to this investigation. The staff member of concern was terminated after an internal investigation was completed by the operation. All remaining employees will receive training on boundaries.


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

Correction Narrative:
During one of the incidents a staff member stated they were in the other room when the child in care showed their self to other children in care. Per the childrens service plans they should be in line of sight or two arms length away from staff members.

Standard was evaluated and found to be compliant.


facility_name: Eden's Place, Inc.

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

raw_content: A staff hired by the operation did not have a pre-employment screening completed.

Category: Personnel

Correction Narrative: on 12/11/25, Director sent the employee's prescreening completed. Also, stated that a two-person review system will be conducted to ensure that all necessary documents prior to employment have been completed and placed in the employee's file.


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

raw_content: There were several hazards that were noted on the current fire inspection that did not meet compliance.  The inspection was conducted on 05/21/2025.

Correction Narrative: The fire department conducted an inspection at the operation on 6/4/25. There were no issues with the inspection. Any previous issues found on the inspection conducted on 5/21/25 were corrected. A copy of the fire inspection was provided.


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

raw_content: The count for a medication was not consistent with the number of pills in the medication bottle.

Correction Narrative: Nine medication logs and medications were reviewed. There were no concerns with the count of the medications. Staff confirmed that training was conducted on April 17, 2025 concerning medication.


summary: 748.3239(b) - Evacuation-Must practice severe weather drill at least once every 6 months from date of last severe weather drill

raw_content: The fire and weather drills were conducted 7 months apart. There one conducted on July 31, 2024, The next one was conducted March 1, 2025.

Category: Safety and Emergency Practices

Correction Narrative: An email was received from the director to document that the drills will be documented on the operation calendar that all staff have access to and a reminder. A staff meeting was conducted on April 17, 2025 to discuss the drills.


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

raw_content: Staff did not document the administration for the medication of Quetiapine for a child in care. Also, a medication log documented administration in the future.

Correction Narrative: Nine mediations logs were reviewed. There were no concerns. Staff confirmed training concerning medication was taken on April 17,2025.


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 staff member gave an incorrect dosage of a prescribed medication to a child in care.

Correction Narrative: Staff were trained on medication adminstration after the incident occurred. All youth discussed no medication errors. Medication logs were reviewed and no concerns.


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

raw_content: Smoke from a vape was smelled and observed coming from the location of children in care while being transported in a vehicle.

Correction Narrative: During the inspection, it was discussed with staff that a new procedure has been added concerning searches. They will be asked for staff to look into bags if they go anywhere outside the operation. This is to ensure that nothing is being brought into the operation. This was also discussed with the youth. An updated policy will also be sent to RCCR.


raw_content: The medication count was pre-filled and therefore the medication count did not match the medication count documentation.

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

Category: Medication

Correction Narrative: Inspector received an email from designee stating that medication log audits will be conducted twice a week to ensure the appropriate medication dosage and quantities are being administered according to the orders prescribed by the physician. The audits will check to see if proper documentation is being recorded at the time that medication is being administered. This was also discussed with the staff the day of the inspection.


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

raw_content: Service plan did not include a plan to address risk of running away.

Correction Narrative: Inspector discussed with the director on completed the service plan with the correct information. This was updated in the child's plan.


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

Deficiency Narrative: Service plan did not include a plan to address risk of running away.

Correction Narrative:
Inspector discussed with the director on completed the service plan with the correct information. This was updated in the child's plan.

4/10/24 the director has updated the service plan to include more specific plans to assist a child with high risk behaviors.


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

raw_content: A child was able to self-harm with razors. Protocols to retrieve razors after use was not completed allowing the child to store razors over time.

Correction Narrative:
Inspector discussed the new process with the director. They have purchased different types of Nair for the girls. The razors have been removed. This was observed at the operation. The Nair is kept in a locked closet. This was also discussed with the girls. They are good with using the Nair.

4/10/24 the director has assessed and decided that they will not allow razors to be used by the girls. They will be purchasing Nair for the girls to use for hair removal.


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

raw_content: During the inspection it was observed that the medication for a child was stored in a weekly medication organizer.

Correction Narrative: All medications are in their original containers. Operation is not using any other containers. This was observed in the walk through of the operation.


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

raw_content: At the time of the inspection, the last annual fire inspection was conducted on 12/30/2022.

Correction Narrative: The operation now has a current fire inspection dated 02/09/2024.


raw_content: During the inspection it was observed that the medication logs did not document the count of the medications administered to children.

Correction Narrative: The count has been added to the medication logs. This was observed in the walk through of the operation.


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

raw_content: The unauthorized absence of a 14-year-old child was not reported timely on 10/19/23 and 10/23/23.

Correction Narrative: An email was received from the CEO of the operation with the staff meeting agenda as well as training certificates for all present staff members on Reporting Serious Incidents. The meeting and training were conducted on 1/2/24.


summary: 748.1207(a)(2) - Placement agreement-Must include a medical consent form signed by a person legally authorized by Texas Family Code to provide consent

raw_content: One out of two children files reviewed had the medical consenter form completed with the GRO staff and not the child's worker.

Category: Admission, Service Planning, Discharge

Correction Narrative: The director/designee sent an email with a copy of the medical consenter completed with the child's case worker information as the medical consenter.


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

raw_content: One out of two children's files reviewed did not document that the operation discussed orientation with the child.

Correction Narrative: The director/designee sent an email with a copy of the child's orientation form that was completed with the child.


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

raw_content: The operation did not have an unauthorized absence log.

Correction Narrative: The director/designee sent an email with a copy of the unauthorized log with all the required information.


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: The TB test results were not available for review in one staff record.

Category: Reports and Record Keeping

Correction Narrative: RCCR Inspector reviewed the TB test results for the staff member missing the TB test. It was completed on 7/5/23 and the results 0n 7/7/23 were negative. A copy is in the sharedrive.


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: The Drug test results were not available to review in one staff record.

Correction Narrative: RCCR Inspector reviewed the test results for the staff member missing the drug test. It was completed on 7/9/23 and the results were negative. A copy is in the sharedrive.


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

raw_content: The operation does not have an administrator currently.

Correction Narrative: The owner and the new administrator sent an email stating that the operation has a new administrator.


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

raw_content: The organizational chart did not include all the positions for the operation. Also, the policies did not include all the written descriptions for all the positions listed on the chart.

Category: Organization and Administration

Correction Narrative: The owner sent a copy of the updated organizational chart to address the current positions and written positions in the policies.


summary: 748.3701(b) - Recreation responsibility-must have a written plan for ensuring that a range of indoor & outdoor recreational & leisure opportunities are provided

raw_content: The operation does not have a written plan for their indoor or outdoor recreation for children.

Category: Recreation Activities

Correction Narrative: Th owner sent a copy of the operation's outdoor recreation for the children.


summary: 748.4201(a) - Admission-Operation must try to contact child's parent(s) within 24 hrs for child admitted for emergency care but who can't consent to services

raw_content: The operation did not address the admission services for emergency care.

Category: Emergency Care

Correction Narrative: The owner updated the 2960 for the operation. The operation will not be offering emergency services.


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

raw_content: The emergency diagrams did not contain areas outside the operation for staff and children meet.

Correction Narrative: Th owner sent updated emergency diagrams to show the areas outside the operation for staff and children meet.


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

raw_content: The agency did not have policies to address the abuse and neglect standard.

Correction Narrative: The owner sent a copy of the operation's updated  abuse and neglect polices.


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

raw_content: The admission polices did not include the goals or services provided by the operation.

Correction Narrative: The owner sent a copy of the update policies to include the admission policies with the goals or services provided by the operation.


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 operation's discipline policies did not address Guide caregivers and employees in the methods used for the discipline of children, integrate trauma informed care into the care, treatment, and management of each child, measures for positive responses to appropriate behavior, or the importance of nurturing behavior, stimulation, and promptly meeting the childs needs.

Correction Narrative: The owner sent updated policies to include the discipline polices. A copy of the complete policies has been uploaded to the sharedrive.


facility_name: Ayanti Residential Treatment Center Inc

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

raw_content: Multiple children interviewed in this investigation stated that staff member was on the phone during an outing at a park. This resulted in the staff member not witnessing multiple kissing incidents between children in care.

Correction Narrative: 4 out of 4  children interviewed denied staff using cellphones around them. 5 out of 5 staff interviewed denied using cellphones around the children. All  staff stated they have been retrained on no use of cell phones around children. The operation has come into compliance with this standard.


summary: 745.621(a)(2) - AP Initial background checks submitted - At the time you hire someone

raw_content: A staff member working at the operation had not had a background check completed.

Correction Narrative:
The Administrator provided a CAP stating all transactions done during their absence will be reviewed immediately upon their return. Ayanti will conduct monthly audit and review of all files to determine compliance, instead of doing so quarterly. Lastly, all onboarding requirements including background checks have been uploaded into ECP (Ayanti electronic system). The system will automatically generate notifications and alerts for missing documents. Candidates will not be activated until all requirements are met.

In addition, the worker had been on suspension without pay due to non-compliance with training requirements even before the issue was brought to their attention. The worker was facing termination; and as of 6/7/2025, was terminated.


raw_content: Interviews completed confirmed that overnight caregiver fell asleep while on shift.

Correction Narrative: Ayanti submitted a plan to maintain 24 hour awake supervision. Documents uploaded to document library.


summary: 748.2203(c)(2) - Medication Error-Document the medication error

Correction Narrative:
Mutiple children have missed medication doses and there was no medical error documentation.

Corrected: Staff responsible for improper documentation has been terminated and all documentation following investigation has been correctly input according to operations training standard. Documentation submitted in document library.


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

Correction Narrative:
Three children in care are not receiving their medication as prescribed due to medication running out.

Corrected: Medicaid prohibits early refills. Solution is to have the operation billed for necessary refills until medicaid reimburses. Documentation submitted in document library.


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

raw_content: The thermometer observed in the refrigerator indicated the temperature was at 49 degrees Fahrenheit.

Category: Physical Site

Correction Narrative: New thermometers were placed in each refrigerator and freezer. Staff has been re-education to revert back to the facility policy on checking thermometers.


summary: 748.3701(a) - Recreation responsibility-Must provide daily indoor/outdoor recreational & other activities appropriate to needs, interests, and abilities of children

raw_content: The operation recreational activity calendar does not have indoor and outdoor recreational activities daily, some days only have indoor activities. In addition, the recreation should be planned according to the children's needs, interests and abilities.

Correction Narrative: The Recreation plan was updated to reflect indoor/outdoor activities for each day. In addition, a disclaimer was added to address recreational needs for children with special circumstances. The plan will be modified as needed.


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

raw_content: The operation menu is not maintained daily there is a generic "summer menu" and also does not include any alternatives.

Correction Narrative: An adjustment was made to the menu to reflect the food being served each dday, on a monthly basis. Staff has been educated on the new process. In addition, menu was place on the refrigerator for staff to check the daily meals.


raw_content: The emergency evacuation plans posted upstairs did not have a designated location indicated as to where the caregivers and children meet. The diagram also does not indicate where one is standing to follow the emergency evacuation plan.

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

Correction Narrative: meeting point was indicated on revised evacuation plan diagram. each room on each floor reflect the new diagram.


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: Multiple employees were inactivated more than 7 days after being terminated.

Correction Narrative: After further review of this element, it was determined that the validation for the employee in question was done in a timely manner, however, there was an error on the termination date noted on file. The employee background check first cleared on a provisional basis, then conditional. Her actual  start date was indeed in May 2023, however, it was mistakenly recorded that the employee's termination date was May 2023 (start date), instead of November 2023 which was her actual termination date. Close attention will be paid when updating information in the internal records to avoid errors like these from happening again.


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

raw_content: It was found that a shower rod was rusted, and a toilet handle was missing in a bathroom accessible to children.

Correction Narrative: The rusted shower rod was changed. In addition, to the broken handle in the hallway bathroom was also replaced. Staff are now required to conduct a thorough walk through each shift, that includes bathroom, closet, etc., to identify issues with items that are not working properly, in order to report them in a timely manner.


summary: 748.3353(b)(1) - Monitoring Devices-Parent, or other person legally authorized to consent, must consent to the use of the video camera

raw_content: It was found in a child's file that the caseworker did not consent the use of a video camera .

Correction Narrative: Revised Admission assessment was emailed to inspector on 12/17/2022 at 12:10 am. The revision address 748.3353: Monitoring devices (see the revision in the document library of Ayanti RTC.


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

raw_content: During the 3rd initial monitoring inspection 6 children in care medication records were reviewed. it was discovered that 3 of the children in care cumulative records were not updated correctly. 3 out of 6 Medication logs reviewed had a different number of pills listed from the prescription package.

Correction Narrative:
Ayanti GRO administrator provided  the inspector the medication test used to obtain feedback from the medication administration training conducted at Ayanti to cure the deficiency cited on 2/1. I have also attached the list of employees and the score obtained.

Also, I am in the process of purchasing a secure hippa complaint electronic platform where caregivers will be able to document, and medication count will be updated as the information is  imputed in the system. This will provide several more layers of safety, decrease potential for medication errors, and improve record keeping for each child entire record.


summary: 748.1217(c)(3) - Admission Assessment-Prior to initial service plan, add child's birth and neonatal history

raw_content: During the inspection, 1 of 5 reviewed records was found to not have information of neonatal history.

Correction Narrative:
On 12/17/2022 Ms. Fisher emailed the inspector at 12:10 am a revised Treatment Center
Admission Assessment for the child in care Neonatal History. (A copy of the revision will be placed in the CCR digital storage under the agency's name and inspection number that occurred on 12/09/2022.


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: During the inspection, it was found that since the operation opened in April (9 mths), they have never validated their employee list.

Correction Narrative: On 12/13/2022 the facility validated the background list. Please see the people list with the date of 12/13/2022 and an updated personnel master listed on 12/19/2022. The updated master list is in the CCR digital storage.


summary: 748.1217(b)(15) - Admission Assessment-At admission, must include child's understanding of the placement

raw_content: During the inspection, it was found that the admission assessment did not mention the child s understanding of placement in 1 of 5 records.

Correction Narrative:
Revised Admission assessment was emailed to inspector on 12/17/2022 at 12:10 am.
State the child's understanding of the placement: I have included this information in the document reviewed by the rep. Please find it in blue. I will request a review of this item because the information is there available in the admission package, just not in the specific section the rep reviewed. It was also signed by the child. (See revised copy in the CCR digital storage under Ayanti's Monitoring inspection follow-up section.


summary: 748.1217(c)(6) - Admission Assessment-Prior to initial service plan, add child's school history

raw_content: During the inspection, it was noticed in 1 of 5 reviewed records that there was no previous school history.

Correction Narrative: Revised Admission assessment was emailed to inspector on 12/17/2022 at 12:10 am. The revision address in the child school history: (see the revision in the CCR digital storage section of Ayanti Monitoring inspection follow up section.


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

raw_content: During inspection, it was found that 1 of 4 staff records reviewed did not have a First Aid certificate.

Category: Training and Professional Development

Correction Narrative: Follow up information was emailed to inspector on 12/17/2022 at 12:10 am. the emailed stated the following:  An employee is missing the first aid certification- the employee has been provided with 14 calendar days as of 12/13/22 (12/27/22) to complete the first aid training. Failure to provide a copy of the said document within the allotted time will result in termination of employment. In the meanwhile, the employee will not be able to provide care to the children independently. This employee will work with another competent employee at all times until the certification is obtained. The letter will be placed in the CCL Storage under the facility's name.


raw_content: During the inspection, it was found that 4 employees who no longer worked at the operation were still active in the People's List after 7 days.

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

Correction Narrative: On 12/17/2022 and 12/19/2022 Ms. Fisher provided the inspector by email with an updated Personal Master list with information pertaining to the 4 employer that are no longer employed by Ayanti. a copy is located in CCR digital storage.


summary: 748.3301(i) - Physical Site-Equipment and furniture must be safe for children and must be kept clean and in good repair

raw_content: During the inspection two hanging poles in the closets upstairs were lose and easily removeable.


summary: 748.109(2) - Admission Policies - include characteristics of the population the program serves

raw_content: At the time of review, admission polices did not state the type of behaviors the operation accepts.

Correction Narrative:
Operation owner emailed corrected admission polices that now include behaviors accepted at the facility.

New policy document added to SharePoint.


facility_name: New Life Childrens Treatment Center

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

raw_content:
During a review conducted on February 20, 2026, it was determined that:

(1)    your operations administrator failed to ensure compliance with the current HM Plan(s); and

(2)    12 months had elapsed since the effective date of the plan.

As you know, the heightened monitoring plans for your operation included a specific planned end date at the 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of post plan monitoring.  As a direct result of the administrators failure to ensure timely compliance with heightened monitoring plans, your operation is now unable to successfully move to post-plan monitoring.  Furthermore, your operations planned end date must now be revised, and the period of heightened monitoring must be extended again.

Further details of the failure of your operations administrator to ensure compliance include the following:
- Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring, including having an open investigation(s).

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

Correction Narrative: An HM extension was approved effective 2/20/26.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your GRO in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 748.535(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is 8/21/2026.


raw_content:
During a review conducted on August 19, 2025, it was determined that:
(1)	your operations administrator failed to ensure compliance with the current HM Plan; and
(2)	more than 12 months had elapsed since the effective date of the plan.
As you know, the heightened monitoring plan for your operation included a specific planned end date at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of post plan monitoring.  As a direct result of the administrators failure to ensure timely compliance with heightened monitoring plan, your operation was unable to successfully move to post-plan monitoring by the original planned end date necessitating previous extension.  Furthermore, due to your recent citations issued on June 6, 2025, your operations planned end date must now be revised again, and the period of heightened monitoring must be extended again.
Further details of the administrators failure to ensure compliance include the following:
Your operation received a high weighted citation in a pattern/trend category on June 6, 2025.  Specifically, the operation was cited for 748.685(a)(4): Caregiver responsibility - During DFPS investigation staff reported having earphones on and admitted to having their eyes closed while working the overnight shift. The purpose of this standard is to protect the health, safety, and well-being of children by ensuring adequate supervision. Supervision is a basic element to the prevention of harm. The operation met compliance on 7/10/2025.
-	Operation failed to satisfy the conditions of the plan.
-	Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring.
-	Operation was unable to meet compliance with high weighted licensing citation.
Finding: 748.535(2)  The licensed administrator must ensure the operation complies with current heightened monitoring plan.

Correction Narrative: An HM extension was approved effective 8/19/2025.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your GRO in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 748.535(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is 2/18/2026.


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

raw_content: Suicide screening that was provided was denied to have been completed by staff and child in care.

Correction Narrative:
8/27/2025 Follow-up by inspection (4072748), discussed with medical staff the process of documenting required information related to screenings in the operation online system.

7/31/2025 email received with CAP, trainings sign-in sheet and email about one-on-one conversation with staff involved.


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

raw_content: Suicide screening was not completed immediately after child in care was found with a t-shirt around their neck.

Correction Narrative:
8/27/2025 Follow-up by inspection (4072748), medical staff was interviewed regarding the screening process and documenting required information in the operation online system.

7/31/2025 email received with CAP, trainings sign-in sheet and email about one-on-one conversation with staff involved.
CAP-Immediate Action:
 One-on-one supervision will be conducted with the nurse and therapist involved by 07.31.2025 to review scenarios that would prompt a suicide screen, accurate reporting expectations, coordinating documentation responsibilities, and what to expect during regulatory interviews.
 Refresher training will be completed with the nurse and therapist involved by 07.31.2025 in suicide screening procedures, documentation protocols, and post-incident debrief expectations.
 While this is will not be the norm quality assurance will provide one-on-one feedback by 07.31.2025 on how to properly document information on that has been gathered via a phone call whether  in real time or during a follow-up.

Ongoing Monitoring and Process Improvement:
 This plan ensures that identified situations are addressed promptly and accurately through intensified oversight and clearly defined performance expectations.
 We will continue to monitor the proper completion of suicide risk screenings in all situations where a child exhibits warning signs that warrant such assessments. Any gaps in practice will be addressed immediately through targeted coaching and support to reinforce consistent adherence to suicide screening protocols.


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 medication count was documented incorrectly on the med log for a child s  prescribed medication.

Correction Narrative:
The operation provided the following corrective action via email on 05.27.25:

1. Targeted Training for Medical Team
a. The identified medical staff will receive refresher training on the proper procedure for
documenting medication counts, including how to record pills administered, remaining
inventory, and discarded medication.
b. The training will emphasize the importance of accuracy in Medication Administration Records
(MAR) and will include examples of common documentation errors and how to avoid them.
c. Completion Deadline: June 3, 2025.
2. Oversight and Quality Assurance Review
a. A MAR audit will be integrated into the daily medical communication log to ensure consistency
and promote daily accountability.
b. Medication Administration Records will be audited "two deep": the first audit will be completed
by the Residential Medical Supervisor, followed by a second review conducted by a member of
administration
3. Upcoming EMAR Implementation
a. New Life is in the process of rolling out an Electronic Medication Administration Record (EMAR)
system this summer. This system includes built-in safeguards to prevent medication
documentation discrepancies, such as real-time inventory tracking, auto-calculation of remaining
doses, and immediate alerts for missing entries.
b. We believe this transition will significantly enhance medication accuracy and accountability
across all shifts.
Identified staff training certificate and training sign-in sheet received.


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

raw_content: During DFPS investigation staff reported having earphones on and admitted to having their eyes closed while working the overnight shift.

Correction Narrative:
07/17/2025- received training sign-in sheet list overnight staff.

07/16/2025- FOLLOW-UP inspection conducted, interviewed the Director of Operations on steps taken. MSR- left PENDING, until training documents received. Training schedule for the evening of 7/16/2025.

07/15/2025- email received from operation stating training will be completed on 7/16/225 instead of 7/15/2025 as indicated in CAP. One day extension granted.

07/10/2025 CAP received from operation:
Policy Reinforcement: All overnight direct care staff will receive refresher training on supervision standards, with emphasis on alert supervision while youth are sleeping, and inattentiveness, no later than 07/15/2025.

Enhanced Monitoring: For the next 60 days, the Residential Dorm Supervisor working the overnight shift will increase the dorm walk-throughs to two per hour between the hours of 12:00 am and 5:00 am to verify staff is alert and offer additional short breaks if staff need to step outside to refresh.
Performance Accountability: Supervisors will document monthly follow-up conversations to make sure all overnight staff are aligned with supervision best practices and any future infractions will be addressed through progressive disciplinary action up to and including separation.

Ongoing Oversight:
The overnight residential dorm supervisor will be granted camera access to monitor all dorm staff for alertness through the overnight hours. The Program Manager will be responsible for verifying the completion of the refresher training as well as follow-up supervisions.

AR will not be requested.


raw_content: A child in care, with identified high risk behaviors, was not provided 15-minute wellness checks and was left alone in the residence by a staff member.

Correction Narrative:
6/13/2025 received email with CAP- We are submitting the following corrective action plan for this investigation and will not be requesting an
administrative review.

This failure is supervision created a serious safety concern and was addressed immediately. Upon internal review, it was determined that this was an isolated incident caused by a single staff member's failure to follow established supervision protocols. This was not reflective of broader practice and was promptly addressed as a targeted performance issue. Existing procedures and training were found to be clear and comprehensive; therefore, no
adjustments are needed to overall supervision policies or trainings are required at this time.
1. Immediate Action:
a. In response, the staff member was required to complete one-on-one coaching with the Program
Trainer as part of the broader corrective actions outlined in their internal Performance Improvement
Plan.
b. This session focused on supervision best practices, including executing line-of-sight visual checks during 15-minute intervals, the expectations outlined in the 24-Hour Awake Supervision policy, and the importance of thorough room checks, particularly during transitions.
2. Performance Oversight:
a. The identified staff member was placed on the highest level of an internal Performance Improvement Plan, effective immediately.
i. For the first 30 days, the Residential Dorm Supervisor will conduct increased documented
supervision, including unannounced spot checks and direct observation during transitions.

Additionally, the staff's monthly supervisions with the Program Manager will increase to a
bi-monthly schedule for a period of three months to review documentation and performance feedback.
iii. While the Performance Improvement Plan is an internal accountability tool, we want to note
that this incident will be treated with zero tolerance for the duration of the plan, which in
this case will span 12 months.
3. Ongoing Monitoring and Process Improvement:
a. This plan ensures that the identified staff member is held directly accountable through intensified oversight and clear performance expectations.
b. We will continue to monitor supervision practices across all shifts. Any gaps will be addressed promptly through targeted coaching and support to reinforce consistent adherence to supervision expectations.


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

raw_content: The Administrator's position has been vacant for more than 60 days.

Correction Narrative:
4/8/2025-During inspection met with new Administrator.

4/4/2025 CAP received from the operation.
A licensed administrator had been hired prior to the monitoring visit and began employment on April
2025.
2. The Chief Operating Officer will oversee and ensure timely staffing of key leadership positions.

An Administrative Review will be requested.


summary: 748.3115 - Fire Extinguisher-Must inspect fire extinguisher(s) monthly

raw_content: Fire extinguisher are NOT being inspected monthly.

Correction Narrative: A follow inspection was completed, the operation provided documentation for the fire extingusher inspections.


raw_content:
During a review conducted on February 13, 2025, it was determined that:
(1)	your operations administrator failed to ensure compliance with the current HM Plan; and
(2)	more than 12 months had elapsed since the effective date of the plan.
As you know, the heightened monitoring plan for your operation included a specific planned end date at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of post plan monitoring.  As a direct result of the administrators failure to ensure timely compliance with heightened monitoring plan, your operation was unable to successfully move to post-plan monitoring by the original planned end date necessitating previous extension.  Furthermore, due to your recent citations issued on December 16th, 2024, your operations planned end date must now be revised again, and the period of heightened monitoring must be extended again.
Further details of the administrators failure to ensure compliance include the following:
Your operation received high weighted citation in a pattern/trend category on December 16, 2024.  Specifically, the operation was cited for 748.685(a)(3): Caregiver responsibility - Child in care was left unsupervised inside the dorm. The purpose of this standard is to protect the health, safety, and well-being of children by ensuring adequate supervision. Supervision is a basic element to the prevention of harm. The operation met compliance on 1/01/2025.
-	Operation failed to satisfy the conditions of the plan.
-	Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring.
-	Operation was unable to meet compliance with high weighted licensing citation.
Finding: 748.535(2)  The licensed administrator must ensure the operation complies with current heightened monitoring plan.

Correction Narrative: An HM extension was approved effective 2/13/2025.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your GRO in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 748.535(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is 08/14/2025.


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

raw_content: Caregivers and children provided corroborating information that a staff member behaved inappropriately with children in care.

Correction Narrative:
Follow-up conducted by inspection. Staff was interviewed regarding training received. A copy of the training sign-in sheet was also obtained.

3/4/2025 Email received from operation with CAP:
1. Targeted training for all staff who interact with the youth
All staff who interact with the youth, including supporting departments, will receive a one-hour
training on Creating Healthy & Appropriate Relationships
The training will emphasize Building Bridges Initiative & Therapeutic Crisis Intervention (TCI)
strategies to foster meaningful and trauma informed relationships with youth.
Completion Deadline: March 18th 2025.
2. Compliance Monitoring
This newly developed training will be included in our list of annually trained topics and the
Program Trainer will ensure that all staff are compliant with the annual trainings.

Weekly management meetings will include a brief review of direct-care staff performance,
specifically with the goal of identifying any individuals who could benefit from additional training in healthy relationship building.
Any identified staff needing additional support will: Receive targeted follow-up training.
Participate in bi-weekly check-ins with a supervisor, management team member,
and/or trainer for a period of 90 days.
Operation will request AR.


summary: 748.1101(b)(1)(C) - Children's rights-Adhere to the child's right to receive fair treatment

raw_content: It was confirmed that a staff member gave gifts to a child and showed them preferential treatment.

Correction Narrative:
Follow-up will be conducted by inspection. Staff was interviewed regarding training received. A copy of the training sign-in sheet was also obtained.

3/4/2025 Email received from operation with CAP:
1. Targeted training for all staff who interact with the youth
All staff who interact with the youth, including supporting departments, will receive a one-hour
training on Creating Healthy & Appropriate Relationships
The training will emphasize Building Bridges Initiative & Therapeutic Crisis Intervention (TCI)
strategies to foster meaningful and trauma informed relationships with youth.
Completion Deadline: March 18th 2025.
2. Compliance Monitoring
This newly developed training will be included in our list of annually trained topics and the
Program Trainer will ensure that all staff are compliant with the annual trainings.

Weekly management meetings will include a brief review of direct-care staff performance,
specifically with the goal of identifying any individuals who could benefit from additional training in healthy relationship building.
Any identified staff needing additional support will: Receive targeted follow-up training.
Participate in bi-weekly check-ins with a supervisor, management team member,
and/or trainer for a period of 90 days.
Operation will request AR.


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

raw_content: On video, a staff member was seen shoving a child to prevent them from going into the room of a peer.

Correction Narrative:
Follow-up conducted; training documents received see MI#4044427

2/12/2025 email received.
Corrective Action Plan:
To ensure compliance with regulatory standards and prevent future incidents, the following corrective actions will
be implemented:
1. Targeted Staff Retraining
-The TCI Certified Trainer will provide one-on-one retraining to the staff member identified in the
video.
 The 2-hour retraining will focus on TCI interventions for de-escalation and managing crisis situations as well as reviewing the footage through the lens of TCI.
-Completion Deadline: February 21, 2025
2. Child Rights Training for All Direct Care Staff
- All direct care staff will receive Child's Rights training emphasizing the right to be free from harsh, cruel, unusual, unnecessary, demeaning, or humiliating treatment or punishment
(748.1101(b)(4)(A)) and 748.2303 (Subchapter M) Discipline & Punishment.
- Completion Deadline: February 21, 2025
3. Compliance Monitoring
-The Program Trainer will ensure that all staff remain current on TCI Refresher courses and Child
Rights trainings.
-The Program Manager and/or Manager on Duty will continue to review and debrief all critical
incidents with direct care staff to identify and implement additional training as necessary.


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

raw_content: Child in care was left unsupervised inside the dorm.

Correction Narrative:
12/31/2024-follow up conducted at the operation discussed with Director and management systems put in place to ensure youth are accounted for. Postings were also observed during inspection.
12/22/2024 email received from operation
Corrective Action:
1. Immediate Action:
 A visual "Headcount" posting will be prominently displayed by or on the doors as a constant
reminder for staff to complete multiple headcounts, particularly when transitioning to and from
the dorms.
 The Residential Dorm Supervisor (RDS) will conduct an additional walk-through of all dorms
immediately after the last dorm transitions to school each day. This ensures that all children are
accounted for.
 If the RDS is unavailable due to unforeseen circumstances, the RDS will immediately contact the
administration building to arrange for an alternative staff member to complete the room checks.
2. Daily Accountability:
 This procedure has been added to the morning RDS's daily checklist. The checklist will be
reviewed daily by either the Manager on Duty (MOD) or the Program Manager (PM) to ensure
compliance.
3. Monitoring and Follow-up:
 The MOD or PM will review the completion of the RDS's morning checklist to ensure consistent
adherence to the corrective action. Regular audits will be conducted as needed to assess the
effectiveness of this plan and ensure ongoing compliance.


summary: 748.303(a)(11)(A) - Serious Incident-Report to Licensing no later than 24 hours after awareness that a child contracts reportable communicable disease

raw_content: The operation did not report a diagnosed communicable disease to licensing.

Correction Narrative:
11/20/2024- follow up conducted with operation. Director has met with head nurse and discussed the systems put in place.
During inspection 4030806 posting mention in #2 in CAP was observed and information was also confirmed by speaking with the nurse.

11/13/24- An email was sent by the operation's Director of Operations with the following compliance response: " Corrective Action: 1. The Program Trainer will review the RTC Reportable incident Guide with a focus on medical incidents as well as the Texas DSHS Administrative Code Chapter 97.3(a)(1-5) What Condition to Report and What isolates to Report or Submit.
2. The most current list of the Texas Notifiable Conditions form the TXDSHS website will be posted in the medical building for easy reference.
3. Any lab results will be reviewed timely by medical staff and supervisor before uploading into EVOLV.
4. Weekly medical updates will be an added topic to staffing meetings, so the reportable conditions can have ongoing monitoring with Directors and Managers.


raw_content:
During a review conducted on August 12, 2024, it was determined that:

(1)	your operations administrator failed to ensure compliance with the current HM Plan(s); and

(2)	more than 12 months had elapsed since the effective date of the plan.

As you know, the heightened monitoring plans for your operation included a specific planned end date at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of post plan monitoring.  As a direct result of the administrators failure to ensure timely compliance with heightened monitoring plans, your operation was unable to successfully move to post-plan monitoring by the original planned end date necessitating previous extension.

Furthermore, due to your recent citations issued on June 03, 2024, your operations planned end date must now be revised again, and the period of heightened monitoring must be extended again.

Further details of the failure of your operations administrator to ensure compliance include the following:
The operation received a medium high weighted citation in a pattern/trend category on June 03, 2024. Specifically, the operation was cited for 748.125(d)3: Suicide Screening - Document that any person conducting a suicide screening meets the conditions and training requirements. Compliance of deficiency was met on July 02, 2024.

-	Operation failed to satisfy the conditions of the plan
-	Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring
-	Operation was unable to meet compliance with medium high weighted licensing citation.

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

Correction Narrative: An HM extension was approved effective 8/12/2024.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your GRO in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 748.535(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is 02/13/2025.


summary: 748.125(d)(3) - Suicide Screening- Document that any person conducting a suicide screening meets the conditions and training requirements.

raw_content: The operation provided an intake suicide screening tool used at admission on a child in care with no documentation of the personnel who administered the tool having the training to do so.

Correction Narrative: Reviewed employee's suicide training certificate.


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

raw_content: A child in care did not receive medical treatment for a fracture until two days after their injury.

Correction Narrative:
7/11/2024- all medical staff will review and sign a copy of 748.1531 acknowledging understanding the importance and receive additional training on the operations after-hours & weekend incident on-call guide.
The training will cover specific procedures to follow during non-office hours for different incidents focusing on illness, injury and other medical incidents. The training will also address timelines and who to notify. Staff will be provided a copy of the on-call guide and reference chart after completions of the training, completed no later than 7/16/2024.
The guide and chart will be posted in the nurse's office. Both topics will be reviewed and discussed in 1:1 Supervisions over the next few months.
7/18/2024- staff training and signed acknowledgement form was received. Confirmed guide was posted in cottage office.


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

raw_content: According to an incident report reviewed, a child disclosed of past sexual abuse. A report was not made to licensing until three days after a staff member and therapist became aware.

Correction Narrative: Follow up inspection conducted.


summary: 748.2001(a) - Administration of Medication-Must obtain a general written consent to administer routine, preventive, & emergency medications

raw_content: Medical consenter was not notified child in care received prescription medication until after the medication was given.

Correction Narrative: On 5/6/24, an inspection was conducted. It was verified that the Medical Team will complete the DFPS Medical Consent Training for Caregivers by Friday, May 10th. It was noted that the name and telephone number of the prescribing health-care professional is listed on the child's service plan which the case worker receives a copy of. Medication administration records and medical consent forms were reviewed for five children.


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

raw_content: Two children in care were involved in a physical altercation. When staff separated the children, this left other residents unsupervised leading to another child in care being assaulted.

Correction Narrative:
On 5/21/24, a follow up inspection was conducted. A staff was interviewed regarding supervision with no concerns presenting. A walkthrough was conducted and no concerns for supervision were observed.

On 5/7/24, the administrator responded that all direct care staff will receive a training on Mileu Management by 5/17.


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

raw_content:
During a review conducted on February 8, 2024, it was determined that:

(1)	your operations administrator failed to ensure compliance with the current HM Plan(s); and

(2)	more than 12 months had elapsed since the effective date of the plan.

As you know, the heightened monitoring plans for your operation included a specific planned end date at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of post plan monitoring.  As a direct result of the administrators failure to ensure timely compliance with heightened monitoring plans, your operation was unable to successfully move to post-plan monitoring by the original planned end date necessitating previous extension.

Furthermore, due to your recent citations issued on February 1, 2024, your operations planned end date must now be revised again, and the period of heightened monitoring must be extended again.

Further details of the failure of your operations administrator to ensure compliance include the following:
The operation received a medium weighted citation in a pattern/trend category on February 1, 2024. Specifically, the operation was cited for 748.2151(c)(6): Medication record - must include name & signature of person who administered each medication. The purpose of the signature is to be able to identify the person who administered a specific medication to a child if a concern arises later about that medication. Compliance of deficiency remains pending.
-	Operation failed to satisfy the conditions of the plan
-	Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring

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

Correction Narrative: An HM extension was approved effective 2/8/2024.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your GRO in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 748.535(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is 08/09/2024.


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

raw_content: The name/sigature of the staff who administered medications to a child in care was  missing from the  medication log.

Correction Narrative: On 2/6/24, the Administrator responded that the staff member who missed the signature for one child will receive 5 days of 1:1 supervision with a Medical Care Coordinator, while passing medication to verify it is administered correctly and documented correctly. This observation time will be documented and completed by February 14th. The medication record was corrected and provided to the inspector for review.


raw_content: Multiple staff became aware of indications of neglectful supervision on the day it occurred. An incident report was not written at this time. The incident was called into the hotline 3 days after awareness.

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


raw_content: Five children in care were left unattended on unit for ten minutes. During this time, one child pushes two children.


summary: 748.537(a) - On Call Staff-A person designated to handle emergencies must be on call and accessible to caregivers

raw_content: Two children were in a physical altercation and the staff supervising was unable to intervene successfully to prevent harm to a child. Support staff was not available to respond immediately to the incident. The child involved had a history of physical altercations requiring safety precautions.

Correction Narrative:
On 1/2/24, a follow up inspection was completed. Supervision and ratio were observed compliant on a walkthrough. Staffing was discussed with management. A child and staff were interviewed with no concerns for supervision/ratio.

On 12/27/23, the administrator responded that the Program Director, Program Manager, and Manager-On-Duty will review, with program staff, Minimum Standard 748.1009(2) and Policy # RTC 501 Child-Caregiver Ratios that requires a sufficient number of caregivers to provide supervision to children in care. The operation continues to implement a staffing plan to increase staff available.

During the administrative review process, it was determined that standard 748.537(a) was a more applicable standard for the finding. Previous follow up was determined to meet compliance.


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

raw_content: During a walkthrough of the cottage, hair and other debris was found on the bathroom sink counter and the floor.


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

raw_content: Emergency evacuation signs did not notate a designated relocation area outside the operation.


raw_content: Two direct care staff admitted to using profane language in the presence of children in care.

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


summary: 748.3563(c) - Protective Surfacing-If loose-fill surfacing materials are used, the operation must install 9 inches or more of uncompressed loose-fill material

raw_content: Licensing observed and photographed the surfacing material under the swings to be worn to down to the earth and  the surrounding surfacing material to be compacted.


raw_content: A child was escorted by police to a psychiatric hospital. Operation staff did not accompany the child. At the hospital, the child filled out the admission's paperwork and listed an unauthorized parent. The individual was able to gain knowledge of the incident and childs whereabouts.


summary: 748.1693(a)(1) - Nutrition-Provide food of adequate variety, quality, and in sufficient quantity to supply the nutrients needed for proper growth and development

raw_content: During face to face interviews of the victim and collateral children, all five children in care stated they do not receive a sufficient quantity of food at meal times and are not allowed seconds even if they state they are hungry. All five also stated alternatives are not provided.

Correction Narrative:
On 11/7/2023, a follow up inspection was completed. A staff and child were interviewed. No concerns for nutrition disclosed. The kitchen was observed with plenty of food to meet the census. A photo was taken of the operation's menu.
On 10/24/23, the administrator provided a compliance response via email. Kitchen staff will attend a review session covering USDA Food regulations and guidelines that direct the amount of food they serve in the three meals and one snack per day requirement. In addition, the Kitchen Manager will inventory and review the measuring utensils to verify that correct proportions are being made during meal preparation. In addition, we will have the Program Manager, Manager-On-Duty, and assigned Residential Shift Lead observe a meal distribution for all three meals, breakfast, lunch, and dinner.


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

raw_content: During the second restraint the child was observed being quiet and still for several minutes. Staff did not provide an opportunity for the child to be released.

Correction Narrative:
On 11/7/2023, a follow up inspection was completed. A staff and child were interviewed. Restraints were discussed. No concerns for restraints or releasing according to minimum standards rules was disclosed. Three restraint reports were reviewed with no concerns. Interactions between caregivers and children observed were positive during the walkthrough.

On 10/24/23, the administrator provided a response via email. Direct Care Staff will attend a TCI Review - The Letting Go Process, which talks about how to let go of the restraint safely. This training will be completed by November 7th, 2023. In addition, Residential Shift Leads are now assigned into each dorm, for their entire shift, to provide additional support and increased oversight on the behavior and work performance of Direct Care Staff. Also, we have recently filled the Manager-On-Duty position whose primary responsibility is to provide additional oversight and on-the-spot training to Direct Care Staff.


raw_content: Video footage showed that staff allowed resident to walk past them while at the same time a dispute between residents in their room was happening and another staff was trying to handle the situation behind them. Staff in the hallway didn't attempt to prevent the resident from running into the other resident's dorm which led to punching the victim.

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


raw_content:
During a review conducted on August 8, 2023, it was determined that:

(1)	your operations administrator failed to ensure compliance with the current HM Plan(s); and

(2)	more than 12 months had elapsed since the effective date of the plan.

As you know, the heightened monitoring plans for your operation included a specific planned end date at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of post plan monitoring.  As a direct result of the administrators failure to ensure timely compliance with heightened monitoring plans, your operation was unable to successfully move to post-plan monitoring by the original planned end date necessitating previous extension.

Furthermore, due to your recent citations issued on August 3, 2023, your operations planned end date must now be revised again, and the period of heightened monitoring must be extended again.

Further details of the failure of your operations administrator to ensure compliance include the following:
The operation received a high weighted citation in a pattern/trend category on August 3,2023. Specifically, the operation was cited for 748.685(a)(4) Caregiver responsibility - being able to intervene when necessary to ensure child's safety.    The operation has until August 16, 2023, to meet compliance on.
-	Operation failed to satisfy the conditions of the plan
-	Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring
-	Operation was unable to meet compliance with High weighted licensing citations

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

Correction Narrative: An HM extension was approved effective 8/8/2023.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your GRO in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 748.535(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is 02/07/2024.


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

raw_content: Direct care staff admitted a child in care was left behind in a residential area for 30 minutes. The child in care was not supposed to be alone for more than 15 minutes as per the child in care's service plan. Video footage also confirms this.


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

raw_content: Medication administration was observed between 8:40 am and 8:51 am. The medication record was not updated from the scheduled medication administration time of 8 am. The time was not documented with the correct time of administration.

Correction Narrative: The operation reviewed the citation and medication record with the staff involved. The discussion included review of the code, specifically focused on time recording requirements. In addition, the updated medication records were provided to the inspector for review.